Approach to the solitary pulmonary nodule · Approach to the solitary pulmonary nodule A solitary pulmonary nodule (SPN) is currently defined as a single pa-renchymal lung lesion

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Approach to the solitary pulmonary nodule

A solitary pulmonary nodule (SPN) is currently defined as a single pa-renchymal lung lesion which is 3 cm or less in diameter, and relatively spher-ical in contour. Some authorities consider that this definition does not ap-ply if there are major surrounding or associated abnormalities on a stan-dard chest radiograph. SPNs provide some of the more vexing clinical chal-lenges facing a pulmonary practitioner. These lesions are common, as ap-proximately 170,000 SPN are detected each year in the United States1.Approximately 1 in 500 standard chest radiographs in adults will show anSPN2 (GL).

Solitary pulmonary nodules are malignant, usually bronchogenic car-cinomas, in 20-40% of cases3. Early resection of a malignant nodule im-proves the otherwise dismal prognosis of bronchogenic carcinoma2,3. Inseveral reports, the 5-year survival has been as high as 75-80%4,5. Resec-tion of a benign nodule however, rarely confers significant benefit to thepatient, and carries its own likelihoods for mortality and morbidity.

MANAGEMENT GOALS

The goals are to resect all malignant SPNs promptly, and, at the sametime, to avoid resection of benign nodules where possible. The criterionhas always been, and still is, that an indeterminate nodule should beregarded as malignant unless proof of benignity can be obtained. Conse-quently, the most important practical question is how to differentiatebenign from malignant (or probably) SPNs prior to surgery.

TESTING FOR BENIGNITY

Two criteria for benignity of SPNs were proposed in the 1950s: nod-ular calcification and retrospective stability6 These are useful and stillemployed, although it is now clear that some modifications of this dic-tum are required7,8.

Intranodular calcification may present a variety of appearances. Fea-tures indicative of benignity include central, diffuse, concentric rings or"popcorn" patterns. Patterns of eccentric calcification or multiple small

L.T. Vaszar,G.A. Lillington

Palo Alto Medical Foundation

Key words: lung, nodule, diagnosis, lung cancer,screening

Correspondence:Glen A. Lillington, M.D.OmbudsmanPalo Alto Medical Foundation795 El Camino RealPalo Alto, CA 94301

18 ÐÍÅÕÌÙÍ Ôåý÷ïò 1ï, Ôüìïò 16ïò, IáíïõÜñéïò - Áðñßëéïò 2003

concentric deposits can be benign or malignant (Fig-ure 1), and in such cases, transthoracic needle biopsyor even diagnostic thoracotomy may still be indicated.Absence of calcification favors malignancy, but doesnot prove it. Even in a nodule with central calcifica-tion, malignancy is occasionally present9. With any ap-parently benign calcification pattern, it is prudent tomonitor with serial x-rays or CT scans for severalmonths or a year to detect growth, which might suggestmalignancy.

Retrospective stability implies little or no growth ofthe nodule, and is ordinarily assessed by comparison ofany available prior chest x-rays with the current imag-es. Stability has traditionally been defined as no de-tectable increase in nodule size during the previous 24months or longer. This criterion is not always absolute,mainly because attempting to detect and monitorgrowth of small nodules using standard x-rays some-times provides misleading results. In such instances, asmall nodule may double or even triple in size beforethe increase in volume is recognized10. The accuracy ofdetecting growth is improved if the nodule is 1.0 cm orgreater in diameter.

Prior computed tomographic (CT) scans, if avail-able, are much more reliable in assessing retrospectivestability than standard chest x-rays, particularly if thenodule is small (less than 10 mm in diameter). Retro-

grade assessment of nodule growth by comparing CTimages with standard chest x-ray images may lead toserious errors10.

If the time interval between the first available andcurrent images is less than 2 years, it is may be appro-priate in many instances to continue the evaluation withCT scans at 3-6 month intervals.

BIOPSY TESTS

Transthoracic needle aspiration biopsy. This rela-tively simple and safe test can be very valuable, and isoften decisive. The test has a 80 to 95% sensitivity formalignancy, and a specificity of approximately 50%11.The biopsy needle is positioned under fluoroscopic orCT guidance.

If the biopsy fails to establish that the nodule is ma-lignant, there are two further possibilities. The biopsymaterial may provide convincing evidence for a specif-ic benign lung disease, in which case the nodule is usu-ally classified as "benign". If the biopsy material is notdefinitive for either malignant or benign disease, theclassification is "indeterminate". In the latter situation,it is often desirable to repeat the biopsy. On-site tech-nology for immediate sampling of the biopsy materialfacilitates repeat sampling in a single session and re-duces the likelihood of "indeterminate" results12,13.

In the case of solitary nodules, an endobronchialbiopsy through a bronchoscope has a relatively low sen-sitivity, unless the lesion is large in size and central inlocation. It is only employed occasionally in patientswith SPNs.

IMAGING TESTS

Computed Tomography (CT). Chest CT is not ableto definitively establish malignancy or benignity in mostsolitary nodules, but it will often provide informationthat is very helpful in estimating the likelihood of ma-lignancy. CT is invaluable in determining whether thelesion is intrapulmonary, and provides much more ac-curate measurements of nodular diameters13. It mayalso demonstrate hitherto unsuspected multiple lesionsin the lungs.

CT may prove or strongly suggest that the lesion is

Figure 1. Patterns of calcification in solitary pulmonary nod-ules. A, central; B, laminated; C, diffuse; D, popcorn; E, stip-pled, and F, eccentric. Patterns A through D are virtually al-ways indicative of benignity. Pattenrs E and F may occur inbenign or malignant nodules. (From Lillington GA: Systemicdiagnostic approach to pulmonary noduls, in AP Fishman [ed]:Pulmonary Disease and Disorders [ed 2]. New York, McGraw-Hill, 1988, p 1947. Used by permission).

19PNEUMON Number 1, Vol. 16, January - April 2003

benign if the nodule is a hamartoma, a vascular lesion,or has a benign calcification pattern not apparent inthe standard chest x-rays.

Features suggestive of malignancy include large sizeof the nodule, certain features of the nodule-lung in-terface (Figure 2), the absence of calcification, and de-monstrable proof of growth of the nodule with serial x-rays or CT scan studies. CT is superior to standard chestroentgenograms in all of these respects, and also pro-vides valuable information on the possible presence ofenlarged mediastinal nodes.

Magnetic Resonance Imaging (MRI) is not usefulfor the detection or identifying malignancy in solitary

nodules, but it can be helpful in detecting and assessinghilar/and mediastinal adenopathy.

Positron Emission Tomography (PET). The PETscan modality now plays a major role in the evaluationof solitary nodules14,15. The most accurate and helpfultechnique is a combined CT/PET scan, which is partic-ularly helpful for achieving precise localization of theabnormality. The overall sensitivity for tumors is 96.8%,but false negative results may occur with bronchoalve-olar tumors, and with malignant nodules less than 1 cmin diameter. As false positives may occur in active in-flammatory lesions, the specificity is only 77.8%14. Apositive result strongly suggests malignancy and sur-gery should be actively considered. A negative PET scanstrongly suggests benignity, but does not absolutely ruleout malignancy.

PET scans are also very helpful in detection of hi-lar, mediastinal and even distant metastases16.

CALCULATION OF THE PROBABILITY OF CANCER(PCA)

An estimate of the probability that the solitary nod-ule is a cancer is useful in the formulation of manage-ment strategies. The value of PCA can be calculated byan assessment of "predictor variables", which includeclinical data (age, smoking history, presence or absenceof previous malignancies) and radiographic character-istics (position of nodule in the lung, diameter of thenodule, edge characteristics, cavity wall thickness, andpresence or absence of calcifications). Bayesian analy-sis17,18 or logistic regression19 can be employed to pro-vide a quantitative estimation (PCA) that the SPN ismalignant.

Calculating the PCA of SPNs is simplified by on-line algorithms, which can be accessed from the Inter-net with the following URL: http://www.chestx-ray.com/SPN/SPNProb.html. Experienced observers are capa-ble of estimating PCA with considerable accuracy inmany cases by reviewing the predictor variables with-out formal calculations of probability.

MANAGEMENT STRATEGIES

In practice, most SPNs initially fall into the catego-

Figure 2. Characteristic appearances of nodule edges. Type I issharp and smooth and the probability of cancer based on thisis 20%. Type 2 is sharp but lobulated, and the probability thatthe nodule is malignant is about 45%. Type 3 shows irregularundulations, and one or two spiculations. The likelihood of ma-lignancy is 2:1 in this case. Type 4. There are multiple spicula-tions. This has been termed "corona radiata" or "corona mali-gna". The odds favoring malignancy are 14:1 in such cases. (Re-draw from Siegelman SS, Khouri NF, Fishman EK, et al: Sol-itary pulmonary nodules: CT assessment. Radiology 1986;160(8): 307-312, Used by permission).


ry of "indeterminate". This includes cases in which be-nign patterns of calcification are not present, and ret-rospective determination of stability is not possible ornot decisive.

There are five available strategies in these circum-stances. These are not mutually exclusive, and are of-ten employed sequentially. "Effectiveness" is measuredby 5-year survival after the initial detection of the SPN.Ignoring the presence of the nodule is not an appropri-ate strategy!

Thoracotomy. This is commonly chosen as the ini-tial (and definitive) strategy because it is both diagnos-tic and therapeutic. Decision analysis studies20 suggestthat if the PCA is relatively high (>60 %), prompt tho-racotomy is the most effective and cost-effective strat-egy. However, thoracotomy may be considered at vir-tually any PCA level if the patient and/or the physicianso choose. Surgical mortality is 1-4%. Compared withstandard (classic) thoracotomy, morbidity is lower withVideo Assisted Thoracoscopy (VAT). If other strate-gies are first employed, thoracotomy is necessarily de-layed to some degree, and there is concern that thepassage of time might allow a curable lesion to becomeincurable20.

Transthoracic needle biopsy. This may be employedat any calculated PCA level, and in the past has beenconsidered to be the most effective strategy over inter-mediate levels of PCA (10-60%). A positive biopsy fortumor indicates that prompt thoracotomy is required.If the biopsy proves a specific benign lesion, thoracot-omy is deferred, but it is prudent to follow the subse-quent course of the nodule by serial CT scans for atleast a year.

An indeterminate biopsy result is not proof of be-nignity or malignancy, and further action must be tak-en. In such cases, the further options may include arepeat needle aspiration biopsy, a PET scan, a "Watchand Wait" approach (see below) or a prompt thoracot-omy

"Wait and watch" strategy. This is a prospective de-termination of stability, determined by serial CT stud-ies after the detection of the SPN. It may be a reason-able choice20 if the PCA is very low <10%, but it isimportant that the patient understands the possible"hazard of delay"20,21. The initial CT followup should be

3-6 weeks after the detection of the nodule, and then at3 month intervals for at least two years, or even longer insome cases.

Growth is measured in terms of the "doubling time"- the time taken for the nodule to double its volume.An increase in diameter of 28% indicates a doubling ofvolume. Malignant nodules tend to have doubling timesbetween 80 and 140 days. Benign nodules usually donot grow in size, although slow growth of the nodulemay occur in some instances. Most authorities wouldprobably advise prompt thoracotomy if the calculateddoubling time is shown to be less than one year, butsome malignant nodules have considerably greater dou-bling times. If the lesion has shown any detectable in-crease in size, thoracotomy or VAT is often carried out.

Some students of SPN management consider thatWait and Watch is rarely indicated.

PET Scan strategy. This test has such high sensitiv-ities and specificities that its use is really a strategy, lim-ited only by the restricted availability of the equipmentrequired. Pet scans may be employed in conjunctionwith or following the initiation of other strategies. Arecent study has suggested that PET scan should bethe initial strategy in most cases22.

A positive test strongly suggests malignancy and inmost cases should mandate thoracotomy. If the resultsof PET scans and the PCA are discordant, needle aspi-ration biopsy may be advisable.

MANAGEMENT PATHWAYS

Spherical lung lesions greater than 3 centimeters indiameter are very frequently malignant, and should bebiopsied or resected without delay in most instances.The pathways employed in the assessment of solitarynodules are not very appropriate for these larger mass-es. Factors such as patient preference or the concur-rent presence of serious concurrent diseases must beconsidered. Needle biopsy or PET Scans may help inthe decision process under such circumstances.

Previous chest x-rays or chest CT scans should besought, and compared with the current studies. Thesemay provide a retrograde estimation of stability, regard-less of the size of the nodule or mass. Recognizablegrowth in the prior two years carries a high likelihood


that the nodule is malignant, and resection must be seri-ously considered. Comparison of current with previousstudies may be seriously misleading, particularly if thenodule is small or if previous studies were obtained withstandard x-rays rather than CTs ( Henschke).

Needle aspiration biopsy should be the initial strat-egy if the solitary or multiple pulmonary nodules arepresent in a subject with a prior history of an extrapul-monary neoplasm, or with other clinical features sug-gesting the possibility that the nodule is metastatic. Insome cases a VATS biopsy may be required.

The clinical value of PCA calculation lies in its usein suggesting the most effective management strategyor sequence of strategies. If the calculated PCA is 15-20% or less, the Wait and Watch strategy is reasonablealthough not imperative. Biopsy should still be consid-ered. If the PCA is 60% or greater, prompt thoracoto-my is usually advisable. These suggestions are not ab-solute, and it is clear that the wishes of the patient mustbe given major consideration.

In the intermediate range of probabilities (20 to60%), the use of needle biopsy has generally been fa-vored in most instances. If the biopsy is nondiagnostic,it may be repeated one or more times, and if the resultis still indeterminate, the further two choices includeimmediate thoracotomy, PET scanning, or Watch andWait in selected circumstances. If the biopsy indicatesa specific benign process, including benign tumor orgranulomatous disease, it is often prudent to carry outWatch and Wait, with repeat x-rays or CT scans everythree months for a year or so.

The use of PET scanning has recently been recom-mended as the initial strategy in many or most cases,particularly if the PCA is within the wide intermediatechange. An initial cost-effective study22 provides sup-port for this, although further studies are clearly desir-able.

Ideally, the patient should play an active role in thedecision process. This requires a thorough discussionof the pros and cons of the various strategies.

STAGING

Ìost malignant SPNs fall into the clinical categoryof T1 N0 M0, but it is still important to obtain a high

resolution CT scan of the chest to explore the status ofthe hilar and mediastinal nodes. Enlargement of thenodes does not, in itself, invariably prove nodal involve-ment with tumor. PET scans are particularly helpful inthis situation. Mediastinal node biopsy will sometimesbe required.

SCREENING FOR LUNG CANCER

The development of the helical single pass chest CTscan has spurred attempts to detect and resect lung can-cers as small as 2-3 mm in diameter. The supposition isthat early detection and prompt surgical resection willreduce the mortality from lung cancer. The efficacy ofCT lung screening however remains to be determinedby the several studies now in progress23.

REFERENCES

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2. Lillington GA. Management of solitary pulmonary nod-ules. Dis Mon 1991; 37:271-318.

3. Leef JL III, Klein JS. The solitary pulmonary nodule.Radiol Clin N Amer 2002; 40:123-43.

4. Ost D, Fein A. Evaluation and management of the soli-tary pulmonary nodule. American Journal of Respiratory& Critical Care Medicine, 2000; 162(3 Pt 1): p. 782-7.

5. Williams DE, et al. Survival of patients surgically treat-ed for stage I lung cancer. Journal of Thoracic & Car-diovascular Surgery, 1981; 82(1): p. 70-6.

6. Good C, Wilson T. The solitary circumscribed pulmo-nary nodule: study of seven hundred five cases encoun-tered roentgenologically in a period of three and onehalf years. JAMA, 1958; 166: p. 210-215

7. Lillington GA. Solitary pulmonary nodules; New Winein Old Bottles Curr Opin Pulm Med 2001; 7:242-246

8. Yankelevitz DF, Henschke CI. Does 2-year stability im-ply that pulmonary nodules are benign? AJR. Ameri-can Journal of Roentgenology, 1997; 168(2): p. 325-8.

9. Berlin L. Malpractice issues in radiology: failing to di-agnose lung cancer. Am J Radiol 2003; 180:37-45

10. Yankelevitz DF, Henschke CI. Small solitary pulmo-nary nodules. Radiol Clin North Am, 2000; 38(3): p.471-8.

11. Shaham D. Semi-invasive and invasive procedures forthe diagnosis and staging of lung cancer. I. Percutane-ous transthoracic needle biopsy. Radiol Clin North Am,


2000; 38(3): p. 525-34.12. Stewart CJ, Stewart IS. Immediate assessment of fine

needle aspiration cytology of lung. J Clin Pathol, 1996;49(10): p. 839-43.

13. Shaffer K. Role of radiology for imaging and biopsy ofsolitary pulmonary nodules. Chest, 1999; 116(6 Suppl):p. 519S-522S.

14. Bury T, et al. Evaluation of the solitary pulmonary nod-ule by positron emission tomography imaging. EurRespir J, 1996; 9(3): p. 410-4.

15. Sarinas PSA, Chitkara RK. PET and SPECT in themanagement of lung cancer. Curr Opin Pulm Med 2002;8(4):257-264.

16. Gould MK, et al. Accuracy of positron emission tomog-raphy for diagnosis of pulmonary nodules and mass le-sions: a meta-analysis. JAMA, 2001; 285(7): p. 914-24.

17. Cummings SR, Lillington GA, Richard RJ. Estimatingthe probability of malignancy in solitary pulmonary nod-ules. A Bayesian approach. ARRD, 1986; 134(3): p. 449-52.

18. Gurney JW, Lyddon DM, McKay JA. Determining thelikelihood of malignancy in solitary pulmonary noduleswith Bayesian analysis. Part II. Application. Radiology,1993; 186(2): p. 415-22.

19. Swensen SJ, Silverstein MD, et al. The probability ofmalignancy in solitary pulmonary nodules: applicationto small radiologically indeterminate nodules. Arch In-tern Med 1997; 157:849-855Swenson.

20. Cummings SR, Lillington GA, Richard RJ. Managingsolitary pulmonary nodules. The choice of strategy is a"close call". Am Rev Resp Dis. 1986; 134(3): p. 453-60.

21. Ginsberg RJ. The solitary pulmonary nodule: can weafford to watch and wait? J Thorac Cardiovasc Surg2003; 125:25-6.

22. Gambhir SS, et al. Analytical decision model for thecost-effective management of solitary pulmonary nod-ules. J Clin Oncol, 1998; 16(6): p. 2113-25.

23. Bach PB, Kelley JM, et al. Screening for lung cancer: areview of the current literature. Chest 2003; 123:72S-80S.

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ÁíáðíåõóôéêÜ ðñïâëÞìáôá óôïí åíÞëéêá ìå êõóôéêÞßíùóç

ËÝîåéò êëåéäéÜ: êõóôéêÞ ßíùóç

Ðíåõìïíïëüãïò, Õðåýèõíïò ÌïíÜäáò ÊõóôéêÞò ºíù-óçò Åíçëßêùí, Â' ÐíåõìïíïëïãéêÞ ÊëéíéêÞ, Óéóìáíü-ãëåéï ÃÐÍÁ

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Ç ðëåéïíüôçôá ôùí áóèåíþí ìå êõóôéêÞ ßíùóç ðáñïõóéÜæåé, óå ìé-êñü ÷ñïíéêü äéÜóôçìá áðü ôïí ôïêåôü, öëåãìïíþäåéò äéçèÞóåéò óôïõòâñüã÷ïõò êáé âëåííïðõþäåéò áðïöñÜîåéò ôùí áåñáãùãþí ïé ïðïßåò,ìåôÜ áðü áíôßäñáóç ôïõ ðÜó÷ïíôïò ïñãáíéóìïý (áõîçìÝíá ïõäåôåñü-öéëá, ðñùôåúíÜóåò), ïäçãïýí óå áíáðíåõóôéêÝò ëïéìþîåéò7-9. Óå êáë-ëéÝñãåéåò ðôõÝëùí áðïìïíþíïíôáé õðü ìïñöÞ ÷ñüíéáò áðïßêçóçò, áñ-÷éêÜ S. aureus êáé H. influenzae, åíþ êáôÜ ôçí åöçâéêÞ çëéêßá êáé P.aeruginosa. Ðéóôåýåôáé åðßóçò üôé åðáíáëáìâáíüìåíåò éïãåíåßò ëïéìþ-îåéò, êõñßùò ôïõò ÷åéìåñéíïýò ìÞíåò, äéåõêïëýíïõí ôçí ôá÷ýôåñç áðïß-


êçóç ôùí ðíåõìüíùí áðü ôá âáêôçñßäéá10. Ç óõíÞèçòóõìðôùìáôïëïãßá áðü ôï áíáðíåõóôéêü åßíáé ç áðü-÷ñåìøç, êõñßùò ðõþäçò Þ/êáé áéìáôçñÞ, äýóðíïéá,èùñáêéêü Üëãïò êáé ìåéùìÝíç áíôï÷Þ óôçí êüðùóç.Ç áêôéíïëïãéêÞ åéêüíá äåß÷íåé õðåñäéÜôáóç ôùí ðíåõ-ìüíùí êáé äéáöüñïõ Ýêôáóçò âñïã÷åêôáóßåò, ôùíïðïßùí ç ãåíåóéïõñãüò öõóéïðáèïëïãéêÞ áéôßá ðé-óôåýåôáé üôé åßíáé ïé óõ÷íÝò ëïéìþîåéò êáé ç ÷ñüíéáöëåãìïíÞ. Ç óðéñïìÝôñçóç åßíáé óõíÞèùò áðïöñá-êôéêïý ôýðïõ, ìå åëáôôùìÝíç ôçí FEV1 êáé âïçèÜ óôçíðáñáêïëïýèçóç ôçò ðïñåßáò ôçò íüóïõ êáé ôçò âáè-ìéáßáò åðéäåßíùóÞò ôçò. Ï Ýëåã÷ïò ôùí áåñßùí ôïõ áñ-ôçñéáêïý áßìáôïò êáé ç ìÝôñçóç ôçò SaO2 áîéïëïãïý-íôáé áíÜëïãá ãéá ôçí åìöÜíéóç áíáðíåõóôéêÞò áíå-ðÜñêåéáò ðïõ åßíáé êáé ôï ôåëéêü óôÜäéï ôçò íüóïõ.

Ç áíÜ ôáêôÜ ÷ñïíéêÜ äéáóôÞìáôá åíäïöëÝâéá áíôé-âéïôéêÞ èåñáðåßá óôçñßæåôáé óôï áíôéâéüãñáììá ôçòêáëëéÝñãåéáò ðôõÝëùí êáé óôïí åíÞëéêá Ý÷åé ó÷åäüíáðïêëåéóôéêü óôü÷ï ôç ëïßìùîç áðü P. aeruginosa. ÌßáðñïëçðôéêÞ èåñáðåõôéêÞ ìÝèïäïò, ãéá íá åðéâñáäõí-èåß ç ÷ñüíéá áðïßêçóç, åßíáé ç ÷ïñÞãçóç åéóðíåüìå-íçò óå íåöåëïðïéçôÞ êïëéóôßíçò ìáæß ìå per os óéðñï-öëïîáóßíç11. Ôá ðåñéóóüôåñá åíäïöëÝâéá áíôéâéïôé-êÜ ó÷Þìáôá óõíäõÜæïõí ìßá áíôéøåõäïìïíáäéêÞ ðå-íéêéëëßíç ìå ìßá áìéíïãëõêïóßäç. ÅíáëëáêôéêÜ, óôçèÝóç ôçò ðåíéêéëëßíçò, ìðïñåß íá ÷ïñçãçèåß ìßá êåöá-ëïóðïñßíç (êåöôáæéäßìç Þ êåöåðßìç). ¢ëëá ÷ñçóéìï-ðïéïýìåíá áíôéøåõäïìïíáäéêÜ áíôéâéïôéêÜ åßíáé çáæôñåïíÜìç, ïé êáñâáðåíÝìåò êáé, óå ðåñßðôùóç ðï-ëõáíèåêôéêüôçôáò, ç êïëéóôßíç12. Ôï ìüíï áðü ôï óôü-ìá áíôéâéïôéêü åßíáé ç óéðñïöëïîáóßíç. Ç ðñïëçðôé-êÞ åíäïöëÝâéá áíôéøåõäïìïíáäéêÞ áíôéâéïôéêÞ èåñá-ðåßá êÜèå ôñåéò ìÞíåò, Üó÷åôá áðü ðáñïîýíóåéò ôïõáíáðíåõóôéêïý, Ý÷åé ïäçãÞóåé åäþ êáé áñêåôÜ ÷ñüíéáóå ìßá óçìáíôéêÞ áýîçóç ôïõ ìÝóïõ üñïõ æùÞò13. Ôáôåëåõôáßá ÷ñüíéá, óôá ìåóïäéáóôÞìáôá ìåôáîý ôçò åí-äïöëÝâéáò áíôéâéïôéêÞò èåñáðåßáò ÷ïñçãåßôáé õðüìïñöÞ åéóðíïþí åéäéêü óêåýáóìá ôïìðñáìõêßíçò(Tobi) ÷ùñßò Ýêäï÷á14. ºóçò óçìáóßáò ìå ôçí áíôéâßù-óç åßíáé ç êáèçìåñéíÞ ðáñï÷Ýôåõóç ôùí âñïã÷éêþíåêêñßóåùí êáé ç óùóôÞ äéáôñïöÞ, ìáæß ìå ôç ÷ïñÞãç-óç ðáãêñåáôéêþí åíæýìùí êáé ëéðïäéáëõôþí âéôáìé-íþí óå ðåñßðôùóç ðáãêñåáôéêÞò áíåðÜñêåéáò. ÓôçíêáèçìåñéíÞ åðßóçò èåñáðåßá óçìáíôéêü ñüëï Ý÷ïõíôá âñïã÷ïäéáóôáëôéêÜ, ôá âëåííïëõôéêÜ (rhDNAse -

Pulmozyme), ôá êïñôéêïóôåñïåéäÞ, êáèþò êáé ôá äéïõ-ñçôéêÜ üðïõ åßíáé áíáãêáßá. ¾óôáôï èåñáðåõôéêüìÝôñï ìðïñåß íá åßíáé ç ìåôáìüó÷åõóç ðíåõìüíùí, ÞêáñäéÜò êáé ðíåõìüíùí, ìå éêáíïðïéçôéêÜ áðïôåëÝ-óìáôá. ÁñêåôÝò Ýñåõíåò ãßíïíôáé ôá ôåëåõôáßá ÷ñüíéáóôç ãïíéäéáêÞ èåñáðåßá, óôç ÷ïñÞãçóç öáñìÜêùí ðïõáíáóôÝëëïõí ôçí áðïññüöçóç ôïõ íáôñßïõ (áìéëïñß-äç) êáé ðïõ ðñïêáëïýí Ýêêñéóç ÷ëùñßïõ (UTP), óôááíôéöëåãìïíþäç, êáèþò êáé óå íåüôåñá óêåõÜóìáôáìå äñÜóç êáôÜ ôùí êõñéüôåñùí ìåôáëëÜîåùí15.

Ïé êõñéüôåñåò åðéðëïêÝò ôçò íüóïõ áðü ôï áíá-ðíåõóôéêü åßíáé ç áôåëåêôáóßá, ï ðíåõìïèþñáêáò (ðï-óïóôü åìöÜíéóçò ìÝ÷ñé 19%), ç áéìüðôõóç ëüãù ÷ñü-íéáò öëåãìïíÞò êáé âñïã÷åêôáóéþí, ç áëëåñãéêÞ âñïã-÷ïðíåõìïíéêÞ áóðåñãßëëùóç êáé, ôÝëïò, ç ðíåõìïíéêÞêáñäßá êáé ç áíáðíåõóôéêÞ áíåðÜñêåéá16.

ÓÞìåñá óôéò ðëÝïí ðñïçãìÝíåò ÷þñåò åíçëéêéþíå-ôáé ôï 35% ðåñßðïõ ôùí ðáó÷üíôùí, åíþ ï ìÝóïò üñïòæùÞò öôÜíåé ôá 30 ÷ñüíéá. Ìå ôç óùóôÞ ÷ïñÞãçóç ôùíáíôéâéïôéêþí êáé ôùí Üëëùí âïçèçôéêþí öáñìÜêùí,êáèþò åðßóçò êáé ìå ôá õðü Ýñåõíá íÝá óêåõÜóìáôá,ðéóôåýåôáé üôé èá âåëôéùèåé ç åéêüíá áõôÞò ôçò èáíá-ôçöüñïõ íüóïõ êáôÜ ôá åðüìåíá ÷ñüíéá.

ÂÉÂËÉÏÃÑÁÖÉÁ

1. Shale JD. Cystic fibrosis. BMJ Publishing Group, 1996;52-61.

2. Collins FS. Cystic fibrosis: molecular biology and ther-apeutic implications. Science 1992; 256:774-9.

3. Davis PB. Cystic fibrosis from bench to bedside. N EnglJ Med 1991; 325:575-7.

4. Rommens JM, Iannuzzi MC, Kerem B et al. Identifica-tion of the cystic fibrosis gene: chromosome walking andjumping. Science 1989; 245:1059-65.

5. Stewart B, Zabner J, Shuber AP, Welsh MJ, McCrayPB jr. Normal sweat chloride values do not exclude thediagnosis of cystic fibrosis. Am J Respir Crit Care Med1995; 151:899-903.

6. Knowles MR, Durie PR. What is cystic fibrosis? N EnglJ Med 2002; 347:439-42.

7. Khan TZ, Wagener JS, Bost T, Martinez J, Accurso FJ,Riches DW. Early pulmonary inflammation in infantswith cystic fibrosis. Am J Respir Crit Care Med 1995;151:1075-82.

8. Dal Nogare AR, Toews GB, Pierce AK. Increased sali-vary elastase precedes gram-negative bacillary coloni-


zation in postoperative patients. Am Rev Respir Dis1987; 135:671-5.

9. Plotkowski MC, Beck G, Tournier JM, Bernardo-FilhoM, Marques EA, Puchelle E. Adherence of Pseudomo-nas aeruginosa to respiratory epithelium and the effectof leucocyte elastase. J Med Microbiol 1989; 30:285-93.

10. Sykes DA, Wilson R, Greenstone M, Currie DC, Stein-fort C, ColePJ. Deleterious effects of purulent sputumsol on human ciliary function in vitro: at least two fac-tors identified. Thorax 1987; 42:256-61.

11. Valerius NH, Koch C, Hoiby N. Prevention of chronicPseudomonas aeruginosa colonization in cystic fibrosisby early treatment. Lancet 1991; 338:725-6.

12. ÉããëÝæïò Ç, ÂëÝôóáò ×, ÌðñáôóéÜêïò ×, Áðïóôïëï-ðïýëïõ Ö. ×ïñÞãçóç å.ö. êïëéóôßíçò óå éíïêõóôéêïýòáóèåíåßò ìå ðïëõáíèåêôéêÞ Pseudomonas aeruginosa.

EëëçíéêÞ ÉáôñéêÞ 2001,Ôüìïò 67,Óõìðëçñùìáôéêü ôåý-÷ïò 4:101(163).

13. Pedersen SS, Jensen T, Hoiby N et al. Management ofPseudomonas aeruginosa lung infection in Danish cys-tic fibrosis patients. Acta Paediatr Scand 1987; 76:955-61.

14. Ramsey BW, Pepe MS, Quan JM et al. Intermittentadministration of inhaled tobramycin in patients withcystic fibrosis. N Engl J Med 1999; 340:25-30.

15. Zeitlin PL. Future pharmacological treatment of cysticfibrosis. Respiration 2000;67:351-7.

16. ÉããëÝæïò Ç. ÅðéðëïêÝò ôçò êõóôéêÞò ßíùóçò. Ðñáêôé-êÜ 4çò ÅðéóôçìïíéêÞò Çìåñßäáò Ðáéäéáôñéêþí Áíá-ðíåõóôéêþí ÐáèÞóåùí. ÐáëáéÜ ÐåíôÝëç, ÌÜúïò1995:15-9.

Ðåñéâáëëïíôéêïß, ìç åðáããåëìáôéêïß ðáñÜãïíôåòêáé êáñêßíïò ôïõ ðíåýìïíá

ÐÅÑIËÇØÇ. Ï êáðíüò ôïõ ôóéãÜñïõ áðïôåëåß ôï ìåßæïí åîùãå-íÝò (ìç ãåíåôéêü) áßôéï ôïõ êáñêßíïõ ôïõ ðíåýìïíá. ¸íáò ìéêñüòáñéèìüò ðåñéðôþóåùí ôçò íüóïõ ìðïñåß íá ïöåßëåôáé óå ÜëëáðåñéâáëëïíôéêÜ áßôéá ðïõ åðéäñïýí åßôå áíåîÜñôçôá åßôå óõíåñ-ãéêÜ ìå ôï êÜðíéóìá. Ç åðßäñáóç ðåñéâáëëïíôéêþí êáñêéíïãü-íùí åßíáé ðåñéóóüôåñï åìöáíÞò óå åðáããåëìáôéêïýò ÷þñïõò, üðïõç õðåýèõíç ïõóßá ìðïñåß íá áíåõñßóêåôáé óå ó÷åôéêÜ ìåãÜëåò óõ-ãêåíôñþóåéò. Ùóôüóï, áêüìç êáé ç ìç åðáããåëìáôéêÞ Ýêèåóç óåóõãêåêñéìÝíåò ïõóßåò ìðïñåß íá ïäçãÞóåé óå êáñêéíïãÝíåóç. Ðá-ñüëï ðïõ ç ëåðôïìåñÞò ìåëÝôç ôçò ðåñéâáëëïíôéêÞò åðßäñáóçòðáñïõóéÜæåé ðïëëÜ ìåèïäïëïãéêÜ ðñïâëÞìáôá, åßíáé óáöÝò üôéðáñÜãïíôåò üðùò ôï ñáäüíéï, ôï áñóåíéêü, ï áìßáíôïò, ç áóôéêÞñýðáíóç, êáé óå ìéêñüôåñï âáèìü ç êïéíùíéêï-ïéêïíïìéêÞ êáôÜ-óôáóç êáé ç äéáôñïöÞ, åìðëÝêïíôáé óôçí êáñêéíïãÝíåóç óôïíðíåýìïíá óå ìéêñü áñéèìü ðåñéðôþóåùí. Ç áðïöõãÞ ôùí ðáñá-ãüíôùí áõôþí äåí åßíáé åýêïëç, áëëÜ êáé äåí áíáìÝíåôáé íá åðç-ñåÜóåé óçìáíôéêÜ ôçí åðßðôùóç ôïõ êáñêßíïõ ôïõ ðíåýìïíá åöü-óïí ôï ìåßæïí êáñêéíïãüíï, ï êáðíüò, ðáñáìÝíåé ïõóéáóôéêÜ áíå-îÝëåãêôï. Ðíåýìùí 2003, 16(1):29-37.

ÅÉÓÁÃÙÃÇ

Ï êáñêßíïò ôïõ ðíåýìïíá (ÊÐ) áðïôåëåß ôçí êýñéá áéôßá èáíÜôïõ áðüêáñêßíï óå ðïëëÝò áðü ôéò ïéêïíïìéêÜ áíåðôõãìÝíåò ÷þñåò, ôüóï óå Üí-äñåò üóï êáé óå ãõíáßêåò (28% üëùí ôùí èáíÜôùí áðü êáñêßíï). Ç èíç-óéìüôçôá áðü ÊÐ áíÜ 100.000 óôéò ÇÐÁ ôï 1990 Þôáí 75 Üíäñåò (óõãêñé-ôéêÜ ãéá ôïí ðñïóôÜôç ï áíôßóôïé÷ïò áñéèìüò Þôáí 25) êáé 31,7 ãõíáßêåò(ãéá ôïí ìáóôü 27,4). Ìåôáîý 1973 êáé 1990 ç èíçóéìüôçôá áõîÞèçêå êáôÜ40,7% (ðåñéóóüôåñï óôéò ãõíáßêåò ðáñÜ óôïõò Üíäñåò). Åðßóçò, ç åðß-ðôùóç ôïõ ÊÐ áõîÞèçêå êáôÜ 19,4% óå Üíäñåò çëéêßáò ìåãáëýôåñçò ôùí65 åôþí, åíþ ìåéþèçêå êáôÜ 3,7% óå åêåßíïõò ìå çëéêßá ìéêñüôåñç ôùí 65

Áíô. ÐáðáãéÜííçò

Aëëçëïãñáößá:Ðáôñ. Ãñçãïñßïõ Å' 42542 49 ÈåóóáëïíßêçÔçë./Fax: 2310 324928e-mail: [email protected]

Ðíåõìïíïëüãïò, ÊëéíéêÞ ¢ãéïò ËïõêÜò, Èåóóáëïíß-êç

ËÝîåéò-êëåéäéÜ: êáñêßíïò ðíåýìïíá, ñýðáíóç,áñóåíéêü, áìßáíôïò, ñáäüíéï, äéáôñïöÞ, êáôïéêß-äéá ðôçíÜ, ðåñéâÜëëïí

Âñá÷åßá Áíáóêüðçóç


åôþí. Ç åðßðôùóç áõîÞèçêå óôéò ãõíáßêåò, ôüóï óå åêåß-íåò ìå çëéêßá ìéêñüôåñç ôùí 65 åôþí (64,4%), üóï êáéåêåßíåò ìå çëéêßá ìåãáëýôåñç ôùí 65 åôþí (182%). ÏéìåôáâïëÝò óôçí åðßðôùóç êáé ôç èíçôüôçôá áêïëïõèïýí(ìå õóôÝñçóç ðåñßðïõ 20 åôþí) ôéò êïéíùíéêÝò ôÜóåéòðïõ åðéêñáôïýí ùò ðñïò ôï êÜðíéóìá, ôï ïðïßï õðïëï-ãßæåôáé üôé åßíáé ôï áßôéï ðåñßðïõ ôïõ 85% ôùí èáíÜôùíáðü êáñêßíï1, åíþ ç Ýêèåóç óå Üëëåò êáñêéíïãüíåò ïõ-óßåò óôï åñãáóéáêü êáé ôï åõñýôåñï ðåñéâÜëëïí ìðï-ñåß íá ðáßæåé óõíåñãéêü ñüëï ìå ôï êÜðíéóìá.

Áí áðïìáêñýíïõìå ôï åíåñãçôéêü êáé ðáèçôéêü êÜ-ðíéóìá êáé ôéò åêèÝóåéò óå äéÜöïñåò êáñêéíïãüíåò ïõ-óßåò óôï åðáããåëìáôéêü ðåñéâÜëëïí, èá õðÜñ÷åé ðåñé-èþñéï íá ìéëïýìå áêüìç ãéá êáñêßíï ôïõ ðíåýìïíá;ÏðùóäÞðïôå áí Ýðáõå-ùò åê èáýìáôïò-íá õðÜñ÷åé ïêáðíüò, ï êáñêßíïò ôïõ ðíåýìïíá ìÝóá óå ìåñéêÝò äå-êáåôßåò áðü åðéäçìéêÞ íüóïò èá ãéíüôáí éáôñéêÞ óðá-íéüôçôá. ºóùò áõôü íá áðïôåëåß áêüìç Üðéáóôï üíåéñï,üóï êé áí ôï åõ÷üìáóôå. Ùóôüóï, óå ìéá ôÝôïéá éäáíéêÞêáôÜóôáóç èá ãßíïíôáí ðéï öáíåñïß êáé ðéï óçìáíôéêïßêÜðïéïé Üëëïé ðáñÜãïíôåò êéíäýíïõ ãéá êáñêéíïãÝíå-óç óôïí ðíåýìïíá. Ìå ìåñéêïýò áðü ôïõò ðáñÜãïíôåòáõôïýò èá áó÷ïëçèïýìå åí óõíôïìßá óôç óõíÝ÷åéá.

ÌÅÈÏÄÏËÏÃÉÊÁ ÐÑÏÂËÇÌÁÔÁ

Ôï ðåñéâÜëëïí ïñßæåôáé ùò �Ôï óýíïëï ôùí öõóé-êþí óõíèçêþí êáé ðáñáãüíôùí ðïõ åðéäñïýí óôïõò æù-íôáíïýò ïñãáíéóìïýò� (Ëåîéêü ôçò ÊïéíÞò Íåïåëëçíé-êÞò, ºäñõìá Ìáíüëç Ôñéáíôáöõëëßäç, Èåóóáëïíßêç1998). Ç åðßäñáóç ôïõ ðåñéâÜëëïíôïò óôçí õãåßá áôü-ìùí êáé ðëçèõóìþí Ý÷åé áðü êáéñü áíáãíùñéóèåß, êáéç êáôáíüçóÞ ôçò óõíå÷þò äéåõñýíåôáé. Ùóôüóï, ç ìåëÝ-ôç ôçò åðßäñáóçò áõôÞò ðáñïõóéÜæåé ìåãÜëåò áíôéêåé-ìåíéêÝò äõóêïëßåò. Êáé ôïýôï äéüôé ç Ýííïéá ôïõ ðåñé-âÜëëïíôïò äåí åßíáé óôáôéêÞ: ÌåôáâïëÝò õößóôáôáé ôüóïôï ßäéï ôï ðåñéâÜëëïí, üóï êáé ï Üíèñùðïò ðïõ æåé ìÝóáó' áõôü. ÐáñÜãïíôåò üðùò ôï êëßìá, ïé åðï÷éáêÝò êáéåôÞóéåò ìåôáâïëÝò ôùí êáéñéêþí óõíèçêþí, äéÜöïñáÝêôáêôá öõóéêÜ öáéíüìåíá êáé áíèñþðéíåò ðáñåìâÜ-óåéò (ð.÷. ðüëåìïé), áëëïéþíïõí óõíå÷þò ôç óýóôáóç ôçòáôìüóöáéñáò óå Ýíá äåäïìÝíï ãåùãñáöéêü ÷þñï.

Áðü ôçí Üëëç ðëåõñÜ, ïé ìåôáêéíÞóåéò ôùí áíèñþ-ðùí êáé ôùí ëáþí ãéá åìðïñéêïýò, ïéêïíïìéêïýò, ôïõ-ñéóôéêïýò, êïéíùíéêïýò êáé ðïëéôéêïýò ëüãïõò êáé ïé

ðïéêßëåò äñáóôçñéüôçôåò (ïéêéáêÝò, âéïìç÷áíéêÝò, åìðï-ñéêÝò, øõ÷áãùãéêÝò êôë.) åêèÝôïõí ìåãÜëï ìÝñïò ôïõðëçèõóìïý óå åíáëëáóóüìåíá ðåñéâÜëëïíôá, ìå äéáöï-ñåôéêÞ óýóôáóç áôìüóöáéñáò.

Ãéá íá ãßíïõí ôá ðñÜãìáôá áêüìç ðéï ðïëýðëïêá,óõíÞèùò åîåôÜæïíôáé ïé åðéäñÜóåéò ìåìïíùìÝíùí ïõ-óéþí óôçí õãåßá ôïõ áíèñþðïõ, åíþ óôçí ðñáãìáôéêü-ôçôá ôï ðåñéâÜëëïí ìáò öÝñíåé óå åðáöÞ ìå ðïëýðëïêáìßãìáôá ðïéêßëçò êáé ìåôáâëçôÞò óýóôáóçò. Óå ìéá íüóïüðùò ï ÊÐ, ðïõ ç áíÜðôõîç êáé ç åîÝëéîÞ ôïõ êáëýðôåéðïëëÜ ÷ñüíéá, äåí ìáò åíäéáöÝñåé ìüíï ôï óçìåñéíü Þôï ÷èåóéíü ðåñéâÜëëïí, áëëÜ êáé åêåßíï ôùí ðñïçãïõ-ìÝíùí äåêáåôéþí. Åöüóïí äåí Ý÷ïõìå áêñéâÞ óôïé÷åßáãéá ôç öýóç êáé ôá åðßðåäá ñýðáíóçò óå ðñïçãïýìåíåòåðï÷Ýò, ãéá ôéò óõó÷åôßóåéò ìáò ÷ñçóéìïðïéïýìå õðï-êáôÜóôáôá ìåãÝèç, üðùò ç êáôáíÜëùóç Üíèñáêïò, ïáñéèìüò ôùí êõêëïöïñïýíôùí ï÷çìÜôùí êáé ç ðõêíü-ôçôá ôïõ ðëçèõóìïý. Åßíáé öáíåñü üôé áõôü åéóÜãåéðïëëÜ óöÜëìáôá óôïõò õðïëïãéóìïýò ìáò. Ôá óöÜëìá-ôá áõôÜ ìåéþíïíôáé ìå ôç ìåëÝôç íåùôÝñùí óôïé÷åßùíðïõ âáóßæïíôáé óå áíôéêåéìåíéêÝò êáôáãñáöÝò ôùí ñý-ðùí ôçò áôìüóöáéñáò, üðùò èá äïýìå óôç óõíÝ÷åéá.

ÔÝëïò, ç ýðáñîç åíüò ìåßæïíïò êáé ðïëý äéáäåäïìÝ-íïõ êáñêéíïãüíïõ (êáðíüò ôóéãÜñïõ) äõó÷åñáßíåé ôçíáíß÷íåõóç êáé áðïìüíùóç Üëëùí ìéêñïôÝñùí ðåñéâáë-ëïíôéêþí êéíäýíùí. ¼óï ç óõ÷íüôçôá ôïõ êáðíßóìáôïòèá ìåéþíåôáé, ôüóï ðéï êáèáñÜ èá ìðïñïýìå íá äéá-êñßíïõìå Üëëåò óõó÷åôßóåéò.

ÁðïôÝëåóìá ôùí ðáñáðÜíù ðåñéïñéóìþí åßíáé çìåëÝôç ôçò åðßäñáóçò ôïõ ðåñéâÜëëïíôïò ðÜíù óôçíõãåßá íá åßíáé ãåìÜôç áðü áóôÜèìçôåò ìåôáâëçôÝò, ðïõêÜíïõí åîáéñåôéêÜ äýóêïëç ôçí ðñïóðÜèåéá ôçò áéôéï-ëïãéêÞò óõó÷Ýôéóçò óõãêåêñéìÝíùí ñýðùí ìå óõãêåêñé-ìÝíåò ðáèÞóåéò. Ùóôüóï, áõôü äåí ðñÝðåé íá ìáò áðï-ôñÝðåé áðü ôçí Ýñåõíá óôïí óõãêåêñéìÝíï ÷þñï. ÄåíðñÝðåé íá îå÷íïýìå üôé ïé óðÜíéåò áéôßåò êÜðïéùí êïé-íþí íüóùí áðïäåéêíýïíôáé ìåñéêÝò öïñÝò ðïëý ÷ñÞóé-ìåò áðü åðéóôçìïíéêÞ ðëåõñÜ. Ç Ýëëåéøç á1-áíôéèñõ-øßíçò åßíáé ðïëý áóõíÞèéóôç ùò áéôßá ðíåõìïíéêïý åì-öõóÞìáôïò. Ùóôüóï ç ìåëÝôç ôçò Ýäùóå ðïëýôéìá óôïé-÷åßá ãéá ôçí éóïññïðßá ðñùôåáóþí-áíôéðñùôåáóþí êáéôç óçìáóßá ôçò ãéá ôçí êáôáóôñïöÞ ôïõ ðíåõìïíéêïýéóôïý. Ìå ðáñüìïéï ôñüðï, ç ìåëÝôç óõãêåêñéìÝíùíêáñêéíïãüíùí ïõóéþí ìðïñåß íá öùôßóåé óêïôåéíÜ óç-ìåßá ôçò ðáèïãÝíåóçò ôïõ êáñêßíïõ. Óõíåðþò ïé óðÜ-


íéåò áéôßåò ÊÐ äåí åßíáé áìåëçôÝåò áðü åðéóôçìïíéêÞóêïðéÜ, Ýóôù êáé áí ðïóïôéêÜ Ý÷ïõí ðïëý ìéêñüôåñïìåñßäéï åõèýíçò.

¸÷ïíôáò êáôÜ íïõí ôéò ìåèïäïëïãéêÝò áõôÝò äõóêï-ëßåò, èá åîåôÜóïõìå óôç óõíÝ÷åéá ôïõò ðåñéâáëëïíôé-êïýò (ìç åðáããåëìáôéêïýò) ðáñÜãïíôåò åêåßíïõò ãéáôïõò ïðïßïõò õðÜñ÷ïõí åðáñêÞ �åíï÷ïðïéçôéêÜ óôïé-÷åßá� ãéá êáñêéíïãÝíåóç óôïí ðíåýìïíá, êáèþò êáé êÜ-ðïéïõò Üëëïõò ðïõ ðáñïõóéÜæïõí åíäéáöÝñïí ëüãù äç-ìïóéüôçôïò. Óçìåéþíïõìå üôé ðïëëïß áðü ôïõò ðáñÜãï-íôåò áõôïýò Ýãéíáí êáôáñ÷Þí ãíùóôïß áðü ôçí ðáñïõ-óßá ôïõò óå åðáããåëìáôéêïýò ÷þñïõò, üðïõ ç ÝêèåóçáöïñÜ óå ìåãáëýôåñåò óõãêåíôñþóåéò êáé óõíåðþò ïäç-ãåß óå åìöáíÝóôåñá áðïôåëÝóìáôá. Ôá åõñÞìáôá áðüôçí åðáããåëìáôéêÞ Ýêèåóç ïäÞãçóáí óå ìåëÝôåò óôïåõñýôåñï ðåñéâÜëëïí, üðïõ ç áíß÷íåõóç ôïõ ðñüóèå-ôïõ êéíäýíïõ áðü óõãêåêñéìÝíåò ïõóßåò ãßíåôáé ðéï äý-óêïëç. Ãéá óýãêñéóç, èá ìðïñïýóå êáíåßò íá óêåöèåßôï ðáñÜëëçëï ðáñÜäåéãìá ôïõ åíåñãçôéêïý êáé ôïõ ðá-èçôéêïý êáðíßóìáôïò: Ç âëáðôéêÞ åðßäñáóç ôïõ ðñþ-ôïõ áðïäåéêíýåôáé ðïëý ðéï åýêïëá áðü åêåßíç ôïõ äåõ-ôÝñïõ, ðïõ üìùò äåí åßíáé ïýôå áíýðáñêôç ïýôå áìåëç-ôÝá.

ÊÏÉÍÙÍÉÊÏ-ÏÉÊÏÍÏÌÉÊÇ ÊÁÔÁÓÔÁÓÇ

Ç ãåíéêÞ êïéíùíéêï-ïéêïíïìéêÞ êáôÜóôáóç (ÊÏÊ)êáèïñßæåé óå ìåãÜëï âáèìü ôï ðåñéâÜëëïí äéáâßùóçòôùí áôüìùí (êáôïéêßá, åßäïò êáé óõíèÞêåò åñãáóßáò,åêðáßäåõóç, äéáôñïöÞ êôë.).

ÄéÜöïñåò ìåëÝôåò Ý÷ïõí äåßîåé ìéá áíôßóôñïöç ó÷Ý-óç áíÜìåóá óôïõò èáíÜôïõò áðü ÊÐ êáé ôçí ÊÏÊ.¸ôóé, ãåíéêÜ êáôáãñÜöåôáé äéðëÜóéá èíçóéìüôçôá áðüÊÐ óôéò êáôþôåñåò ôÜîåéò óå ó÷Ýóç ìå ôéò áíþôåñåò, ðïõåí ìÝñåé ïöåßëåôáé óôçí áõîçìÝíç óõ÷íüôçôá ôïõ êá-ðíßóìáôïò óôéò ïéêïíïìéêÜ êáé ìïñöùôéêÜ êáôþôåñåòôÜîåéò. Åðßóçò, ç ÊÏÊ ìðïñåß íá áðïôåëåß Ýììåóï äåß-êôç ãéá Üëëïõò ðáñÜãïíôåò êéíäýíïõ, üðùò ôï åðÜããåë-ìá, ç äéáôñïöÞ êáé ïé ñýðïé ôïõ ðåñéâÜëëïíôïò. Ìðï-ñåß üìùò íá åðçñåÜæåé êáé ôçí ðïéüôçôá, ôçí ðñüóâáóçêáé ôç ÷ñÞóç ôùí õðçñåóéþí õãåßáò, êáé óõíåðþò ôçíÝãêáéñç Þ ìç äéÜãíùóç êáé åðéôõ÷Þ èåñáðåßá ôïõ ÊÐ 1.

Ç ìåëÝôç äéáöüñùí ðëçèõóìþí Ýäåéîå üôé ç åðßðôù-óç êáé ç èíçóéìüôçôá áðü ÊÐ óå äéÜöïñåò ÷þñåò áíôá-íáêëÜ óå ìåãÜëï âáèìü ôéò êáðíéóôéêÝò óõíÞèåéåò ôùí

ðñïçãïõìÝíùí äåêáåôéþí. ÐÝñá áðü ôï ãåíéêü áõôüóõìðÝñáóìá, ðïëý ëßãåò ìåëÝôåò Ý÷ïõí áðïäþóåé åõ-èýíåò óå óõãêåêñéìÝíåò óõíèÞêåò ôïõ ïéêéáêïý ðåñé-âÜëëïíôïò. ÁõôÝò ðïõ áíáöÝñïíôáé óôç âéâëéïãñáößááöïñïýí ó÷åäüí áðïêëåéóôéêÜ óôçí Êßíá (ßóùò äéüôéåêåß, ëüãù ôïõ ìåãÜëïõ ðëçèõóìïý, åßíáé åýêïëï íáìåëåôÞóåé êáíåßò ìåãÜëåò êáé ó÷åôéêÜ ïìïéïãåíåßò ïìÜ-äåò áôüìùí). ̧ ôóé, óå ìéá áãñïôéêÞ ðåñéï÷Þ ôçò åðáñ-÷ßáò ÃéïõíÜí âñÝèçêå áõîçìÝíïò êßíäõíïò ÊÐ ôüóï óåÜíäñåò üóï êáé óå ãõíáßêåò, ðïõ áðïäüèçêå óå ñýðáí-óç ôùí åóùôåñéêþí ÷þñùí áðü ôçí êáýóç ìáëáêïý êÜñ-âïõíïõ ðïõ âãÜæåé ðïëý êáðíü óå ÷þñïõò ðïõ äåí áå-ñßæïíôáé åðáñêþò2. Óôçí áóôéêÞ ðåñéï÷Þ ôïõ ÓåíãéÜíãê(ÂÁ Êßíá), ç åóùôåñéêÞ ñýðáíóç áðü èåñìÜóôñåò ìåêÜñâïõíï ðñïêÜëåóå ó÷åôéêü êßíäõíï ãéá ÊÐ2,3 óôçíïìÜäá ìå ôç ìåãáëýôåñç Ýêèåóç, ìåôÜ áðü äéüñèùóçãéá ôçí çëéêßá, ôçí åêðáßäåõóç êáé ôï êÜðíéóìá3,4. ÔÝ-ëïò, óôç ÓáíãêÜç ï áõîçìÝíïò êßíäõíïò ÊÐ èåùñÞèç-êå üôé ïöåßëåôáé óå ðáñáôåôáìÝíç Ýêèåóç óå áôìïýòìáãåéñéêþí ëáäéþí ðïõ ðáñÜãïíôáé áðü ôçí êáýóç óåõøçëÝò èåñìïêñáóßåò êáôÜ ôï ìáãåßñåìá óå wok5. Äåíåßíáé ãíùóôü áí ïé ðáñáôçñÞóåéò áõôÝò Ý÷ïõí åöáñìï-ãÞ êáé óå Üëëïõò ðëçèõóìïýò.

ÁÔÌÏÓÖÁÉÑÉÊÇ ÑÕÐÁÍÓÇ

Óå ðïëëÝò âéïìç÷áíéêÝò ÷þñåò ç ó÷Ýóç èíçóéìüôç-ôáò áðü ÊÐ ìåôáîý áóôéêþí êáé áãñïôéêþí ðåñéï÷þíêõìáßíåôáé áðü 1,2 ùò 2. ÐñïêåéìÝíïõ íá äïèåß åñìç-íåßá óôçí åðéäçìéêÞ áýîçóç ôïõ ÊÐ óôéò âéïìç÷áíéêÝò÷þñåò, Ý÷åé åñåõíçèåß ç åíäå÷üìåíç åðßäñáóç áôìï-óöáéñéêþí ñýðùí, üðùò åßíáé ôá ðñïúüíôá ôçò êáýóåùòïñõêôþí êáõóßìùí êáé éäßùò ïé ðïëõêõêëéêïß áñùìáôé-êïß õäñïãïíÜíèñáêåò. ¢ëëåò ìåãÜëåò ðçãÝò ñýðùí åß-íáé ïé åêðïìðÝò ôùí áõôïêéíÞôùí êáé Üëëùí ðåôñåëáéï-ìç÷áíþí, ïé óôáèìïß ðáñáãùãÞò åíÝñãåéáò êáé ïé åê-ðïìðÝò áðü ôç âéïìç÷áíßá êáé ôéò êáôïéêßåò. ̧ ÷åé õðï-ëïãéóèåß üôé ç ðáñáôåôáìÝíç Ýêèåóç óå áóôéêÞ ñýðáí-óç áíäñþí ðïõ êáðíßæïõí ìÝôñéá èá ðñïêáëïýóå 10åðéðëÝïí ðåñéðôþóåéò ÊÐ áíÜ 100.000 Üôïìá êáô' Ýôïò1.Ùóôüóï, óôéò ðåñéóóüôåñåò ÷þñåò ðåñßðïõ 80% ôùíêñïõóìÜôùí ÊÐ áðïäßäåôáé óôï êÜðíéóìá, åíþ ï �áóôé-êüò ðáñÜãùí� åßíáé äýóêïëï íá åêôéìçèåß ìå áêñßâåéá,ëüãù ôçò ìåãÜëçò ðïéêéëßáò ðïõ ðáñáôçñåßôáé óôéò êá-ðíéóôéêÝò óõíÞèåéåò. ÅîÜëëïõ, üðùò ðñïáíáöÝñáìå, ç


áôìïóöáéñéêÞ ñýðáíóç áðïôåëåß Ýíá ðïëýðëïêï ìåßã-ìá ÷çìéêþí ïõóéþí êáé óôïé÷åßùí ðïõ ðïéêßëëåé ôüóïãåùãñáöéêÜ, üóï êáé ÷ñïíéêÜ. Ïé äéÜöïñïé ñýðïé Ý÷ïõíáìïéâáßá áëëçëåðßäñáóç ôüóï ìåôáîý ôïõò, üóï êáé ìåôïí êáðíü, êáé áõôü êÜíåé ôçí áîéïëüãçóç åîáéñåôéêÜäýóêïëç.

Óå ìéá ðáëáéüôåñç åðéäçìéïëïãéêÞ ìåëÝôç ôçò Amer-ican Cancer Society õðïëïãßóèçêáí ïé óõ÷íüôçôåò ôïõÊÐ áíÜëïãá ìå ôïí ôüðï êáôïéêßáò, ìåôÜ áðü äéüñèù-óç ãéá ôçí çëéêßá, ôï åðÜããåëìá êáé ôï êÜðíéóìá. ¼ôáíáðïìáêñýíèçêáí ïé ðáñÜãïíôåò áõôïß, áðÝìåéíáí ðïëýìéêñÝò äéáöïñÝò óôç èíçóéìüôçôá áíÜìåóá óå áóôéêÝòêáé åîï÷éêÝò ðåñéï÷Ýò Þ áíÜìåóá óå ðüëåéò ìå äéáöï-ñåôéêïýò äåßêôåò ñýðáíóçò. Ç ìåëÝôç áõôÞ ðéèáíþò äåß-÷íåé ðüóï ïñéáêÞ åßíáé ç åðéâÜñõíóç áðü ðåñéâáëëï-íôéêÝò åêèÝóåéò, Üëëá êáé ðüóï äýóêïëï åßíáé íá óõíá-÷èïýí áêñéâÞ óõìðåñÜóìáôá6. Ùóôüóï, ðÜíù óôï èÝìááõôü õðÜñ÷ïõí êáé íåþôåñá óôïé÷åßá, üðùò èá äïýìåðáñáêÜôù.

¸ñåõíåò óå Üôïìá ðïõ åß÷áí åðáããåëìáôéêÞ Ýêèå-óç óå óõãêåêñéìÝíïõò ñýðïõò ìáò äßíïõí åíäåßîåéò ãéáôç äõíçôéêÞ êáñêéíïãüíï äñÜóç ôùí ñýðùí áõôþí. ̧ ôóé,óå åñãáæïìÝíïõò ðïõ åß÷áí ôáêôéêÞ Ýêèåóç óå åêðïìðÝòáðü êáýóç öõóéêïý áåñßïõ ðáñáôçñÞèçêå, ìåôÜ ôç äéüñ-èùóç ãéá ôïí ðáñÜãïíôá ôïõ êáðíßóìáôïò, äéðëÜóéáóõ÷íüôçôá ÊÐ óå ó÷Ýóç ìå ôïõò ìç åêôåèåéìÝíïõò. Åðß-óçò, åñãÜôåò ìå ôáêôéêÞ Ýêèåóç óå áíáèõìéÜóåéò ðßó-óáò óå áíïéêôü ÷þñï ðáñïõóßáæáí áýîçóç óôïí ÊÐêáôÜ 50% ìåôÜ 20 Ýôç åêèÝóåùò, åíþ ìåôÜ 40 Ýôç ç áý-îçóç Þôáí 150%7. Åßíáé áõôïíüçôï üôé ïé åðáããåëìáôé-êÝò áõôÝò åêèÝóåéò áöïñïýí óå ðïëý ìåãáëýôåñåò óõ-ãêåíôñþóåéò ôùí áíôéóôïß÷ùí ñýðùí áðü áõôÝò ðïõáíåõñßóêïíôáé óôçí åí ãÝíåé áôìüóöáéñá, óôçí ïðïßáåêôßèåôáé ï áóôéêüò ðëçèõóìüò ðïõ äåí áó÷ïëåßôáé åé-äéêÜ ìå ôçí áíÜëïãç äñáóôçñéüôçôá.

Ùò ðñïò ôá áôìïóöáéñéêÜ êáñêéíïãüíá, ôï âåíæï(á)-ðõñÝíéï (ðñïúüí êáýóåùò ïñõêôþí êáõóßìùí) Ý÷åé ÷ñç-óéìïðïéçèåß ùò õðïêáôÜóôáôïò äåßêôçò ãéá ôçí Ýêèåóçóå áóôéêÞ áôìüóöáéñá, êáé ðáñïõóéÜæåé èåôéêÞ óõó÷Ý-ôéóç ìå ôç èíçóéìüôçôá áðü ÊÐ1. ¢ëëåò ïõóßåò ðïõõðÜñ÷ïõí óôïí áóôéêü áÝñá êáé ðéèáíïëïãåßôáé üôéÝ÷ïõí êáñêéíïãüíï äñÜóç åßíáé: áíüñãáíá óùìáôßäéáÞ ßíåò (áñóåíéêü, áìßáíôïò, ÷ñþìéï, íéêÝëéï, ïõñÜíéï),ñáäéïíïõêëßäéá (Pb-210, Pb-212, Rn-222), êáé ïñãáíé-êÝò åíþóåéò óå áÝñéá Þ óùìáôéäéáêÞ ìïñöÞ (ð.÷. äéìå-

èõëïíéôñïæáìßíç, âåíæüëéï, âåíæïðõñÝíéï, 1,2-âåíæáí-èñáêÝíéï).

Ç International Agency for Research on Cancer(WHO) Ý÷åé ÷áñáêôçñßóåé ôéò åîáôìßóåéò ôùí êéíçôÞñùííôÞæåë ùò ðéèáíÜ êáñêéíïãüíåò8. Ïé Garshick êáé óõí.ìåëÝôçóáí åñãÜôåò óéäçñïäñüìùí ðïõ åîåôÝèçóáí óååîáôìßóåéò íôÞæåë êáé êáôÝãñáøáí áýîçóç 40% óôïíó÷åôéêü êßíäõíï ãéá ÊÐ, ìåôÜ áðü äéüñèùóç ãéá ôï êÜ-ðíéóìá9.

¼ðùò áíáöÝñáìå óôçí áñ÷Þ, ç ìåèïäïëïãßá ôçòìåëÝôçò ôïõ ðåñéâÜëëïíôïò âåëôéþíåôáé êáèþò óõëëÝ-ãïíôáé ðëÝïí áíôéêåéìåíéêÜ óôïé÷åßá ãéá ôç ñýðáíóç ôçòáôìüóöáéñáò. ̧ ôóé, óôçí áñ÷Þ ôïõ 2002 äçìïóéåýèçêåÝíá ìÝñïò ôùí áðïôåëåóìÜôùí ìéáò åíôõðùóéáêÞò ìå-ëÝôçò ðïõ äéåîÜãåôáé åðß 20 ÷ñüíéá ôþñá óôéò ÇÐÁ10.Ðñüêåéôáé ãéá ôçí Cancer Prevention II Study ôçò Amer-ican Cancer Society. Óôç ìåëÝôç åíôÜ÷èçêáí óõíïëéêÜ1,2 åêáôïììýñéá åíÞëéêåò ôï 1982. Óôï Üñèñï ðïõ äç-ìïóéåýèçêå áíáëýèçêáí ôá óôïé÷åßá ãéá 500.000 åíÞëé-êåò óå óõó÷åôéóìü ìå ôá äåäïìÝíá ôçò ñýðáíóçò óå ìç-ôñïðïëéôéêÝò ðåñéï÷Ýò ôùí ÇÐÁ, ìÝ÷ñé ôïí ÄåêÝìâñéïôïõ 1998. ÂñÝèçêå üôé ç ñýðáíóç áðü ìéêñïóùìáôßäéáêáé ïîåßäéá ôïõ èåßïõ åß÷å èåôéêÞ óõó÷Ýôéóç ìå ôçí ïëé-êÞ èíçóéìüôçôá êáé ôïõò èáíÜôïõò áðü ÊÐ êáé êáñ-äéïáããåéáêÜ íïóÞìáôá. Õðïëïãßóèçêå üôé ï áñéèìüòôùí èáíÜôùí áðü ÊÐ áõîáíüôáí êáôÜ 8% ãéá êÜèå 10ìg/m3 ìéêñïóùìáôéäéáêÞò ýëçò (<2,5ìm). Áí óõãêñß-íïõìå ôá åõñÞìáôá áõôÜ ìå åêåßíá ôçò ðáëáéüôåñçò ìå-ëÝôçò ðïõ áíáöÝñáìå ðáñáðÜíù, ãßíåôáé öáíåñü üôé ïéãíþóåéò ìáò ãéá ôï ðåñéâÜëëïí âñßóêïíôáé áêüìç óåñåõóôÞ êáôÜóôáóç, êáé óõíåðþò õðüêåéíôáé óå áíáèåþ-ñçóç óõíå÷þò.

ÔÏ ÑÁÄÏÍÉÏ ÔÙÍ ÅÓÙÔÅÑÉÊÙÍ ×ÙÑÙÍ

Ôï ñáäüíéï (Rn 222) åßíáé Ýíá áäñáíÝò, Ü÷ñùìï êáéÜïóìï ñáäéåíåñãü áÝñéï ìå ÷ñüíï çìéæùÞò 3,8 çìÝñåò,ðïõ ðáñÜãåôáé áðü ôç öõóéêÞ äéÜóðáóç ôïõ ïõñáíßïõ238 êáé ôïõ ñáäßïõ 226 êáé õðÜñ÷åé óôï Ýäáöïò, ôá ðå-ôñþìáôá êáé ôï íåñü ôïõ åäÜöïõò. Ìðïñåß íá äéáðåñ-íÜ ôïí öëïéü ôçò ãçò, åíþ ìéêñïðïóüôçôåò ñáäïíßïõáðåëåõèåñþíïíôáé óôïí åðéöáíåéáêü áÝñá áðü ôï Ýäá-öïò, êáèþò êáé áðü äïìéêÜ õëéêÜ. Ëüãù ôçò âåëôéùìÝ-íçò ìüíùóçò ôùí êôéñßùí êáé ôïõ ìåéùìÝíïõ ñõèìïýáíáíÝùóçò ôïõ áÝñá ôùí êëåéóôþí ÷þñùí, ôï ñáäüíéï


ðáñáôçñåßôáé óå áõîçìÝíåò óõãêåíôñþóåéò óå êëåéóôïýò÷þñïõò, üðùò ïé êáôïéêßåò. Óôéò ÇÐÁ õðïëïãßóèçêå üôéç Ýêèåóç óå ñáäüíéï óå åóùôåñéêïýò ÷þñïõò åßíáé õðåý-èõíç ãéá ôï 50-80% ôçò óõíïëéêÞò áêôéíïâïëßáò ðïõêáôÜ ìÝóïí üñï ëáìâÜíåé Ýíá Üôïìï11.

¼ôáí ïé óõãêåíôñþóåéò ñáäïíßïõ åßíáé áñêåôÜõøçëÝò (üðùò Ý÷ïõí êáôáãñáöåß óå ïñõ÷åßá ìåôáë-ëåõìÜôùí ïõñáíßïõ, êáóóéôÝñïõ êáé óéäÞñïõ), ôï ñá-äüíéï êáé ôá ðñïúüíôá äéÜóðáóÞò ôïõ (ðïëþíéï 214êáé ðïëþíéï 218), ðïõ åêðÝìðïõí óùìáôéäéáêÞ á-áêôé-íïâïëßá, Ý÷åé áðïäåé÷èåß üôé ðñïêáëïýí ÊÐ, éäßùò óåêáðíéóôÝò. Ðñïåêôåßíïíôáò ôá äåäïìÝíá áðü ôçí åðáã-ãåëìáôéêÞ Ýêèåóç óôïí ãåíéêü ðëçèõóìü, õðïëïãßóèç-êå üôé ôï ñáäüíéï ìðïñåß íá ðñïêáëåß áðü 6000 ùò24.000 èáíÜôïõò áðü ÊÐ êÜèå ÷ñüíï óôéò ÇÐÁ12. Ìéááðü ôéò ðéï ìåãÜëåò êáé ìåèïäïëïãéêÜ áîéüðéóôåò åñ-ãáóßåò åßíáé ç Iowa Radon Lung Cancer Study13. Ìå-ôáîý 1993 êáé 1997 ìåëåôÞèçêáí 1027 ãõíáßêåò çëé-êßáò 40-84 åôþí óôçí Áúüâá (413 ìå íåïäéáãíùóìÝíïÊÐ êáé 614 ìÜñôõñåò), ðïõ åß÷áí æÞóåé óôï ßäéï óðßôéãéá ðåñéóóüôåñï áðü 20 ÷ñüíéá. Ó÷åäüí óôï 60% ôùíõðïãåßùí ôùí óðéôéþí êáé ôùí äõï ïìÜäùí ôï åðßðåäïñáäïíßïõ Þôáí ðÜíù áðü ôï üñéï ðáñÝìâáóçò ôùí 4pCi/L. ÌåôÜ áðü äéüñèùóç ãéá ôï åíåñãçôéêü êÜðíé-óìá, âñÝèçêå êßíäõíïò ÊÐ áõîçìÝíïò êáôÜ 50% ãéáìÝóç Ýêèåóç åðß 15 ÷ñüíéá óôï åðßðåäï ôùí 4 pCi/L. ÇÁúüâá Ý÷åé ôçí õøçëüôåñç ìÝóç óõãêÝíôñùóç ñáäï-íßïõ óôéò ÇÐÁ ðïõ ïöåßëåôáé óå åíáðïèÝóåéò áðüðáãåôþíåò ðÜíù áðü 10.000 ÷ñüíéá ðñéí.

Ùóôüóï ïé õðïëïãéóìïß áõôïß ðïëý óýíôïìá áìöé-óâçôÞèçêáí, äéüôé ðñáêôéêÜ äåí ìðïñåß êáíåßò íá õðï-ëïãßóåé ôçí ðñáãìáôéêÞ éóüâéá Ýêèåóç óå ñáäüíéï ìåâÜóç ôéò äéáèÝóéìåò ìåèüäïõò ìÝôñçóçò. ÌåëÝôåò óåäéáöïñåôéêÝò ÷þñåò, üðùò ç Óïõçäßá, ï ÊáíáäÜò êáéç Êßíá, Ýäùóáí äéáöïñåôéêÝò åêôéìÞóåéò ôïõ ó÷åôéêïýêéíäýíïõ ãéá ÊÐ, ðïõ êõìáßíïíôáé áðü 1,1 Ýùò 2,9. ÇðñáãìáôéêÞ ôéìÞ ìÜëëïí åßíáé ðëçóéÝóôåñá ðñïò ôï ÷á-ìçëüôåñï üñéï, ðåñßðïõ 1,2, äéüôé óôéò ðåñéóóüôåñåòêáôïéêßåò ç ôéìÞ ñáäïíßïõ åßíáé êÜôù áðü 4 pCi/L, ðïõóôéò ÇÐÁ áðïôåëåß ôï üñéï ðÜíù áðü ôï ïðïßï óõíé-óôÜôáé êÜðïéá ðáñÝìâáóç ìåßùóçò1. Åðßóçò, áðü ôéòìåëÝôåò áõôÝò öÜíçêå üôé ç Ýêèåóç óå ñáäüíéï Ý÷åéü÷é áèñïéóôéêÞ, áëëÜ ó÷åäüí ðïëëáðëáóéáóôéêÞ äñÜ-óç ìå ôïí êáðíü, ãåãïíüò ðïõ äõó÷åñáßíåé áêüìç ðå-ñéóóüôåñï ôçí ðñïóðÜèåéá ãéá áêñéâÞ õðïëïãéóìü ôïõ

áìéãïýò êéíäýíïõ áðü ñáäüíéï êáé ìüíï.Óôïí åëëçíéêü ÷þñï Ý÷ïõí ãßíåé ìåôñÞóåéò ñáäï-

íßïõ óå äéÜöïñåò ðåñéï÷Ýò, êáé ïé áíáöåñüìåíåò ôé-ìÝò åßíáé ó÷åôéêÜ ìéêñÝò, ôçò ôÜîçò ôùí 40 Bq/m3 (=1,08 pCi/L) [éóïäõíáìßá: 1 Bq/m3 = 0,027 pCi/L]. Ùóôü-óï, óôï ðñüóöáôï 1ï Ðåñéâáëëïíôéêü ÓõíÝäñéï Ìá-êåäïíßáò áíáêïéíþèçêáí ôéìÝò ãéá ôçí Áñíáßá ×áë-êéäéêÞò êáé ôéò Âñýóåò Áðïêïñþíïõ ×áíßùí ðïõ ðåñ-íïýí ôá 200 Bq/m3 (Þ 5,4 pCi/L) óå 10% ôïõëÜ÷éóôïíôùí êáôïéêéþí ðïõ åîåôÜóèçêáí14. Ïé ðåñéï÷Ýò áõôÝò÷áñáêôçñßóèçêáí ùò �ñáäoíüðëçêôåò� (radon proneareas).

Ç ÅðéôñïðÞ ãéá ôá ÂéïëïãéêÜ ÁðïôåëÝóìáôá ôçòÉïíßæïõóáò Áêôéíïâïëßáò õðïëüãéóå üôé ðåñßðïõ 10%ôùí ÊÐ óôéò ÇÐÁ êáé 6% óôç Âñåôáííßá ðñïêáëïý-íôáé áðü ôï ñáäüíéï óôï ãåíéêü ðåñéâÜëëïí, ãåãïíüòðïõ èá Ýêáíå ôï ñáäüíéï ôï äåýôåñï óçìáíôéêüôåñïáßôéï ôïõ ÊÐ ìåôÜ ôïí êáðíü15.

ÁÑÓÅÍÉÊÏ

Ôï áñóåíéêü åßíáé öõóéêü ìÝôáëëï ðïõ âñßóêåôáéóõ÷íÜ óôïí öëïéü ôçò ãçò, êáé óå áíüñãáíç ìïñöÞ áðï-ôåëåß áíáãíùñéóìÝíï êáñêéíïãüíï ðáñÜãïíôá ãéá ôïíÜíèñùðï. Ïé êýñéåò ðçãÝò áíïñãÜíïõ áñóåíéêïý óôçíáôìüóöáéñá åßíáé ç åîáãùãÞ ìåôÜëëùí (÷áëêïý, íéêå-ëßïõ, êïâáëôßïõ) ìå ôÞîç óïõëöéäéêþí ìåôáëëåõìÜôùíêáé ç êáýóç ïñõêôþí êáõóßìùí (êáõóôÞñåò, êéíçôÞñåòáõôïêéíÞôùí, èåñìÜóôñåò êáé ôæÜêéá ìå îýëá ê.ëð.). Åðß-óçò áñóåíéêü áðåëåõèåñþíåôáé óå ïñõ÷åßá, êáôÜ ôçíåîáãùãÞ ôïõ ìïëýâäïõ, áðü ôç ãåùñãéêÞ ÷ñÞóç áñóå-íéêïý÷ùí ðáñáóéôïêôüíùí, ôçí áðïôÝöñùóç áðïññéì-ìÜôùí êáé ôç âéïìç÷áíéêÞ ÷ñÞóç áñóåíéêïý÷ùí åíþ-óåùí.

Ï ãåíéêüò ðëçèõóìüò åêôßèåôáé óå áñóåíéêü óôïíáÝñá, ôï íåñü, ôï ÷þìá êáé ôéò ôñïöÝò. Ïé óõãêåíôñþ-óåéò áñóåíéêïý óôçí áôìüóöáéñá ðïéêßëëïõí áðü <3ng/m3 óôçí ýðáéèñï ìÝ÷ñé 20-30 ng/m3 óå áóôéêÝò ðå-ñéï÷Ýò. Ôá åðßðåäá áõôÜ åîáñôþíôáé áðü ôç ãåéôíßáóçìå åðáããåëìáôéêÝò äñáóôçñéüôçôåò ðïõ áðåëåõèåñþ-íïõí áõîçìÝíá ðïóÜ áñóåíéêïý. Ìéá åðéäçìéïëïãéêÞìåëÝôç óå êáôïßêïõò ìéáò ðåñéï÷Þò ãýñù áðü åñãï-óôÜóéï ðáñáóéôïêôüíùí âñÞêå óçìáíôéêÜ áõîçìÝíïêßíäõíï ãéá ÊÐ16. Ï êßíäõíïò áðü Ýêèåóç óå ÷áìçëü-ôåñåò óõãêåíôñþóåéò åßíáé ëéãüôåñï âÝâáéïò.


×ñçóéìïðïéþíôáò óõíôçñçôéêÜ ìáèçìáôéêÜ ðñüôõ-ðá ç Õðçñåóßá Ðñïóôáóßáò ÐåñéâÜëëïíôïò ôùí ÇÐÁõðïëüãéóå üôé ç Ýêèåóç åðß 24 þñåò ôçí çìÝñá åðß 70÷ñüíéá óå ìéá áôìüóöáéñá ðïõ ðåñéÝ÷åé 20 ng/m3 èáðñïêáëïýóå 1 åðéðëÝïí ðåñßðôùóç ÊÐ áíÜ 10,000 Üôï-ìá17.

ÅîÜëëïõ, ç êáôáíÜëùóç ýäáôïò ìå õøçëÝò óõãêå-íôñþóåéò áñóåíéêïý Ý÷åé óõó÷åôéóèåß ìå áõîçìÝíï êßí-äõíï êáñêßíïõ ôïõ äÝñìáôïò óå äéÜöïñåò ÷þñåò (Ôáú-âÜí, ×éëÞ, ÁñãåíôéíÞ, Ìåîéêü), åíþ õðÜñ÷ïõí ðïëý ëé-ãüôåñá óôïé÷åßá ãéá ðéèáíÞ áéôéïëïãéêÞ ó÷Ýóç ìå ÊÐ15.

ÁÌÉÁÍÔÏÓ

Ï áìßáíôïò áðïôåëåß 'êüêêéíï ðáíß' ãéá ôïõò ðíåõ-ìïíïëüãïõò, ëüãù ôçò ãíùóôÞò óõó÷ÝôéóÞò ôïõ ìå ôçíðñïïäåõôéêÞ äéÜìåóç ßíùóç (áìéÜíôùóç), ôï êáêüçèåòìåóïèçëßùìá õðåæùêüôïò êáé ðåñéôïíáßïõ êáé ôç äéÜ-÷õôç ðÜ÷õíóç ôïõ õðåæùêüôïò, áëëÜ êáé ðéï êáëïÞèåéòðáèÞóåéò üðùò ïé õðåæùêïôéêÝò ðëÜêåò êáé ïé áéìïñ-ñáãéêÝò õðåæùêïôéêÝò óõëëïãÝò.

Ïé åðéðôþóåéò ôïõ áìéÜíôïõ óôçí õãåßá Üñãçóáí íáäéáðéóôùèïýí, äéüôé õðÞñ÷å óýã÷õóç ôùí êëéíéêþí êáéáêôéíïëïãéêþí åéêüíùí ìå åêåßíåò ðïõ ïöåßëïíôáí óôçöõìáôßùóç êáé ôçí ðõñéôßáóç. Ï üñïò �áìéÜíôùóç� êá-ôáãñÜöçêå ãéá ðñþôç öïñÜ ôï 1927, êáé ôï ðñþôï ðåñé-óôáôéêü ðíåõìïíéêÞò ßíùóçò áðü áìßáíôï ÷ùñßò ðáñïõ-óßá öõìáôßùóçò äçìïóéåýèçêå ôï 1928. Ôï 1938 ðñïôÜ-èçêå ãéá ðñþôç öïñÜ üñéï áóöáëåßáò ãéá óõãêÝíôñù-óç áìéÜíôïõ óôïí áÝñá (5 åêáôïììýñéá óùìáôßäéá áíÜêõâéêü ðüäé), ôï ïðïßï ðñïïäåõôéêÜ êáôÝâçêå óôï óç-ìåñéíü åðéôñåðôü åðßðåäï ðïõ åßíáé 0,1 ßíá áíÜ ml áÝñá[ôï åðßðåäï áõôü åßíáé 1678 öïñÝò ÷áìçëüôåñï áðü ôïðñþôï!]

Äåí èá áó÷ïëçèïýìå åäþ ìå ôç ãåíéêüôåñç åðéäç-ìéïëïãßá ôùí ðáèÞóåùí ôïõ áìéÜíôïõ. ÐñÝðåé üìùò íááíáöÝñïõìå üôé ÊÐ äåí Ý÷åé êáôáãñáöåß ÷ùñßò ôçí ðá-ñïõóßá áìéÜíôùóçò óôïõò ðñïóâåâëçìÝíïõò ðíåýìïíåò.ÐïëëÝò áíåîÜñôçôåò åðéäçìéïëïãéêÝò êáé ðáèïëïãïá-íáôïìéêÝò ìåëÝôåò Ý÷ïõí óõìðåñÜíåé üôé ï áõîçìÝíïòêßíäõíïò ÊÐ óå Üôïìá åêôåèåéìÝíá óå áìßáíôï ðåñéï-ñßæåôáé óå åêåßíá ðïõ Ý÷ïõí áìéÜíôùóç, ìéá ðÜèçóç ðïõäåí óõìâáßíåé áí äåí Ý÷åé õðÜñîåé óçìáíôéêÞ Ýêèåóçóå áìßáíôï. Ç ðáñáôÞñçóç áõôÞ äõóôõ÷þò äåí éó÷ýåéãéá ôï ìåóïèçëßùìá, ç áíÜðôõîç ôïõ ïðïßïõ äåí ó÷åôß-

æåôáé áðáñáßôçôá ìå ôçí ðáñïõóßá äéÜìåóçò ßíùóçò: çÝêèåóç ðïõ áðáéôåßôáé ãéá ôçí áíÜðôõîç ìåóïèçëéþìá-ôïò ðéèáíþò åßíáé ÷áìçëüôåñç áðü åêåßíç ãéá ôçí áíÜ-ðôõîç ÊÐ, ìå áðïôÝëåóìá íá ðñïêáëåßôáé áðü ðåñéâáë-ëïíôéêÞ, ìç åðáããåëìáôéêÞ Ýêèåóç óå ìéêñÝò äüóåéò18,19.Ï áìßáíôïò áðïôåëåß áíåîÜñôçôï ðáñÜãïíôá êéíäýíïõãéá ÊÐ, áêüìç êáé ÷ùñßò ôç óõíïäü ðáñïõóßá ôïõ êá-ðíßóìáôïò, ìå ôï ïðïßï Ý÷åé ó÷åäüí ðïëëáðëáóéáóôéêÞóõíÝñãåéá. Ç ó÷Ýóç äüóçò-áðÜíôçóçò èåùñåßôáé üôé åß-íáé ãñáììéêÞ, åíþ äåí öáßíåôáé íá õðÜñ÷åé êÜðïéïòïõäüò (= åëÜ÷éóôï áðáéôïýìåíï üñéï Ýêèåóçò).

Óå ìåñéêÝò ÷þñåò Ý÷åé ðñïêáëÝóåé áíçóõ÷ßá óôïêïéíü ôï ãåãïíüò üôé, óå ü÷é ðïëý ðáëéÝò åðï÷Ýò, äïìé-êÜ õëéêÜ ìå áìßáíôï ÷ñçóéìïðïéïýíôáí ðïëý óõ÷íÜ óåïéêïäïìÞìáôá ðïõ åîáêïëïõèïýí íá êáôïéêïýíôáé Þ íá÷ñçóéìïðïéïýíôáé ùò äçìüóéá êôßñéá (ó÷ïëåßá, íïóïêï-ìåßá, õðçñåóßåò). ÐñÜãìáôé, óôïí áÝñá ðïëëþí ïéêïäï-ìþí Ý÷ïõí áíé÷íåõèåß ßíåò áìéÜíôïõ, óå óõãêåíôñþóåéòüìùò ðïëý ÷áìçëÝò, ôçò ôÜîåùò ôçò 0,001 Ýùò 0,0001 ßíáòáíÜ ml. Ìå ôá äåäïìÝíá áõôÜ äåí èá Þôáí äõíáôü íáóõóóùñåõèåß ìéá äüóç åðáñêÞò ãéá ôçí ðñüêëçóç áìéÜ-íôùóçò Þ ÊÐ áðëþò êáé ìüíï áðü ôç äéáâßùóç Þ ôçíåñãáóßá óå êôßñéá ðïõ ðåñéÝ÷ïõí áìßáíôï20. Áíôßóôïé-÷á, ç ìüíç ìåëÝôç ðïõ áó÷ïëÞèçêå ìå ôç íïóçñüôçôááðü ìåóïèçëßùìá óå êáôïßêïõò ïéêïäïìþí ìå ìïíþóåéòáðü áìßáíôï äåí âñÞêå êáìéÜ äéáöïñÜ ìåôáîý êáôïß-êùí êáé ìáñôýñùí21.

Äåí ðñÝðåé íá ðáñáëåßøïõìå óôï óçìåßï áõôü íááíáöÝñïõìå áõîçìÝíç óõ÷íüôçôá ÊÐ, ìåóïèçëéþìáôïòêáé Üëëùí ðáèÞóåùí ðïõ ó÷åôßæïíôáé ìå áìßáíôï ðïõÝ÷åé ðåñéãñáöåß óôçí Êáððáäïêßá óå ðåñéï÷Ýò ðïõ ÷ñç-óéìïðïéïýí ïéêïäïìéêÜ õëéêÜ ðïõ ðåñéÝ÷ïõí öõóéêüåñéïíßôç22. Ðñüêåéôáé ãéá ìéá óáöÞ ðåñßðôùóç ðåñéâáë-ëïíôéêÞò êáñêéíïãÝíåóçò áðü Ýêèåóç óå áìßáíôï.

ÊÁÔÏÉÊÉÄÉÁ ÐÔÇÍÁ ÊÁÉ ÊÐ

Ôï 1988 äçìïóéåýèçêå óôï Âritish Medical Journal(BMJ) ìéá åñãáóßá áðü ôçí Ïëëáíäßá, ç ïðïßá âñÞêåóçìáíôéêÝò êáé áíåîÜñôçôåò óôáôéóôéêÝò óõó÷åôßóåéò ôçòåðßðôùóçò ÊÐ ìå ôï êÜðíéóìá, ôç ÷áìçëÞ ðñüóëçøçâéôáìßíçò C êáé ôçí åêôñïöÞ ðôçíþí óôï óðßôé23. ÌåôÜôç äéüñèùóç ãéá ôï êÜðíéóìá êáé ôç âéôáìßíç C, ï ó÷å-ôéêüò êßíäõíïò áðü ôçí åêôñïöÞ ðôçíþí Þôáí 6,7. Ïéáñéèìïß óôïõò ïðïßïõò âáóßóèçêå ç ìåëÝôç áõôÞ Þôáí


ìéêñïß (49 áóèåíåßò ìå ÊÐ êáé äéðëÜóéïò áñéèìüò ìáñ-ôýñùí). Ïé óõããñáöåßò óôÞñéîáí ôçí õðüèåóÞ ôïõò óôïãåãïíüò üôé ç åêôñïöÞ ðôçíþí áðïôåëåß êõñßùò áíäñé-êü ÷üìðé, üôé ï ìåãáëýôåñïò áñéèìüò ôñïðéêþí ðôçíþí(60-80%) ðùëåßôáé óôçí Ïëëáíäßá, ôï ÂÝëãéï êáé ôç Ì.Âñåôáíßá, üðïõ õðÜñ÷ïõí êáé ïé ðåñéóóüôåñåò ëÝó÷åòðôçíïößëùí êáé ãßíïíôáé ïé ðåñéóóüôåñåò åêèÝóåéò ðôç-íþí, êáèþò êáé óôï üôé ç õøçëüôåñç èíçóéìüôçôá áðüÊÐ óôçí Ïëëáíäßá ìåôáîý 1969-1984 êáôáãñÜöçêå óôçíáãñïôéêÞ åðáñ÷ßá ôïõ Noord Brabant, üðïõ õðÜñ÷ïõíïé ðåñéóóüôåñïé ïñãáíùìÝíïé ðôçíïôñüöïé ôçò ÷þñáò.Ùò ðéèáíÞ åñìçíåßá ãéá ìéá ôÝôïéá óõó÷Ýôéóç ðñïôÜèç-êå ç åéóðíïÞ áëëåñãéïãüíùí êáé óùìáôéäßùí óêüíçò áðüôïõò åêôñïöåßò, ç ïðïßá ðñïêáëåß äõóëåéôïõñãßá ôùíêõøåëéäéêþí ìáêñïöÜãùí êáé ôïðéêÜ åëëåßììáôá óôç÷õìéêÞ êáé êõôôáñéêÞ áíïóßá.

ÌåñéêÜ ÷ñüíéá áñãüôåñá, ïé Kohlmeier êáé óõí. áðüôï Âåñïëßíï áíÝöåñáí áõîçìÝíï êßíäõíï ÊÐ óå åêôñï-öåßò ðôçíþí, ìå odds ratio 2,14 ìåôÜ áðü äéüñèùóç ãéáåíåñãçôéêü êáé ðáèçôéêü êÜðíéóìá êáé åðáããåëìáôéêïýòðáñÜãïíôåò24. Ç åñãáóßá ôïõò ðåñéëÜìâáíå 239 áóèå-íåßò êáé 429 ìÜñôõñåò. Ôçí ßäéá ÷ñïíéÜ (1992) ïé Gar-diner êáé óõí. áðü ôç Óêùôßá25 áíÝöåñáí åðßóçò áõîç-ìÝíï êßíäõíï ÊÐ óå åêôñïöåßò ðåñéóôåñéþí (áëëÜ ü÷éðáðáãÜëùí Þ êáíáñéíéþí) óå ìéá åñãáóßá ìå 143 áóèå-íåßò êáé 286 ìÜñôõñåò. Ïé óõããñáöåßò óõìðÝñáíáí üôéç åêôñïöÞ ðïõëéþí ìðïñåß íá äçìéïõñãåß êÜðïéï êßí-äõíï, ü÷é üìùò ôüóï ìåãÜëï üóï åß÷å ìÝ÷ñé ôüôå áíá-öåñèåß.

Ôï 1996 ïé Modigh êáé óõí. äçìïóßåõóáí ìåëÝôç áðüôï ÐáíåðéóôÞìéï ôïõ Goteborg (Óïõçäßá), óå 380 áóèå-íåßò êáé 696 ìÜñôõñåò, ðïõ äåí âñÞêå êáììßá ó÷Ýóç ôùíðôçíþí ìå ôïí ÊÐ26. Ïé ßäéïé åñåõíçôÝò âñÞêáí ðáñü-ìïéá óõìðåñÜóìáôá óôçí ÁìåñéêáíéêÞ Ðïëéôåßá ôïõÌéóóïýñé27. Óôï ßäéï ôåý÷ïò ôïõ BMJ (ðïõ Ý÷åé äçìï-óéåýóåé ó÷åäüí üëåò ôéò ìÝ÷ñé ôþñá åñãáóßåò ðÜíù óôïèÝìá), ï John Britton ó÷ïëßáæå üôé ïé ðáëáéüôåñåò åñ-ãáóßåò äåí åß÷áí êÜíåé åðáñêåßò äéïñèþóåéò ãéá ôïíðáñÜãïíôá �êÜðíéóìá�, ãåãïíüò ðïõ öáéíüôáí íá åîç-ãåß ôá áíôéöáôéêÜ áðïôåëÝóìáôá28. Ùóôüóï, Üöçíå áíïé-êôü ôï åñþôçìá üóïí áöïñÜ åéäéêÜ óôçí åêôñïöÞ ðåñé-óôåñéþí, ìéá êáé ïé ìåôáãåíÝóôåñåò ìåëÝôåò åß÷áí íáêÜíïõí êõñßùò ìå êáôïéêßäéá ðïõëéÜ üðùò ðáðáãÜëïéêáé êáíáñßíéá.

Ç ôåëåõôáßá åñãáóßá ðÜíù óôï èÝìá äçìïóéåýèçêå

ôï 1998 áðü ôïõò Morabia êáé óõí.: Måëåôþíôáò 887áóèåíåßò Áìåñéêáíéêþí íïóïêïìåßùí ìå ðñùôïäéáãíù-óìÝíï ÊÐ êáé 1350 ìÜñôõñåò, äåí âñÞêáí áðïëýôùòêáììßá óõó÷Ýôéóç ìå ôçí åêôñïöÞ êáôïéêéäßùí ðôç-íþí29. Öáßíåôáé üôé ìåôÜ áðü ôéò ìåëÝôåò áõôÝò, ìå ìå-ãÜëï áñéèìü áóèåíþí êáé åðáñêåßò äéïñèþóåéò ãéá ôïêÜðíéóìá, ôá ðïõëéÜ (åêôüò ôùí ðåñéóôåñéþí) ìÜëëïíáðáëëÜóóïíôáé áðü ôçí êáôçãïñßá ôçò êáñêéíïãÝíå-óçò.

ÄÉÁÔÑÏÖÇ ÊÁÉ ÊÐ

Óôï ðëáßóéï ôùí ðåñéâáëëïíôéêþí ðáñáãüíôùí äåíìðïñïýìå íá áãíïÞóïõìå ôç äéáôñïöÞ, ôçí êáôáíÜëù-óç äçëáäÞ èñåðôéêþí ïõóéþí ðïõ ðñïÝñ÷ïíôáé áðü ôïðåñéâÜëëïí áõôü êáé åðçñåÜæïõí ôïí ìåôáâïëéóìü êáéôç ãåíéêüôåñç êáôÜóôáóç ôçò õãåßáò ôùí áôüìùí. ÊáéðÜëé, ç ó÷Ýóç ôçò äéáôñïöÞò ìå ôçí êáñêéíïãÝíåóç åß-íáé äýóêïëï íá äéåñåõíçèåß åðáñêþò êáé ìå áêñßâåéá.Ùóôüóï, áñêåôÝò åðéäçìéïëïãéêÝò ìåëÝôåò ðñïóðÜèç-óáí íá óõó÷åôßóïõí ôçí åðßðôùóç ÊÐ ìå ôçí êáôáíÜ-ëùóç óõãêåêñéìÝíùí äéáôñïöéêþí óõóôáôéêþí. Ôï êïé-íü åýñçìá ôùí ìåëåôþí áõôþí Þôáí ìéá áíôßóôñïöç ó÷Ý-óç áíÜìåóá óôç äéáéôçôéêÞ ðñüóëçøç öñïýôùí êáé ëá-÷áíéêþí êáé ôïí êßíäõíï ãéá ÊÐ, êáèþò êáé ãéá Üëëïõòüãêïõò30. Ç ðåñéóóüôåñç Ýñåõíá Ý÷åé ãßíåé ó÷åôéêÜ ìåôï â-êáñïôÝíéï, ç ðñïóôáôåõôéêÞ äñÜóç ôïõ ïðïßïõ åß-íáé éäéáßôåñá öáíåñÞ óå åíåñãïýò Þ ðñþçí êáðíéóôÝò.Ðïéêßëåò ìåëÝôåò óå äéÜöïñåò ÷þñåò Ý÷ïõí äåßîåé üôé:(á) ÷áìçëÞ ðñüóëçøç ëá÷áíéêþí êáé öñïýôùí ó÷åôßæå-ôáé ìå áõîçìÝíï êßíäõíï ÊÐ, êáé (â) ÷áìçëü åðßðåäïâ-êáñïôåíßïõ óôïí ïñü ó÷åôßæåôáé ìå êßíäõíï ìåôÝðåé-ôá áíÜðôõîçò ÊÐ31. ÐÜíôùò õðÜñ÷ïõí åíäåßîåéò üôé ïóõíäõáóìüò öõóéêþí áíôéïîåéäùôéêþí ïõóéþí, üðùòð.÷. áíåõñßóêïíôáé óôá ìÞëá, åðéôõã÷Üíåé ðïëý éó÷õñü-ôåñç áíáóôïëÞ ôïõ ðïëëáðëáóéáóìïý ôùí êáñêéíéêþíêõôôÜñùí áðü áõôÞ ðïõ ðñïêáëåß Ýíá óõìðëÞñùìá äéá-ôñïöÞò (ð.÷. âéôáìßíç)32.

ÓÕÌÐÅÑÁÓÌÁÔÁ

Áðü ôç óýíôïìç áõôÞ áíáóêüðçóç ìðïñïýìå íá óõ-ìðåñÜíïõìå ôá áêüëïõèá:� Ï áéôéïëïãéêüò ñüëïò ôïõ ðåñéâÜëëïíôïò äéáâßù-

óçò (ìå åîáßñåóç ôïí åñãáóéáêü ÷þñï) óôçí êáñ-


êéíïãÝíåóç ôïõ ðíåýìïíá åßíáé äýóêïëï íá åêôéìç-èåß ìå áêñßâåéá.

� ¼ôáí áðïìáêñõíèïýí ïé ðáñÜãïíôåò ôïõ åíåñãçôé-êïý êáé ðáèçôéêïý êáðíßóìáôïò êáé ôùí åðáããåë-ìáôéêþí åêèÝóåùí, ç ðñüóèåôç åðéâÜñõíóç ðéèáíü-ôáôá åßíáé ìéêñÞ.

� Óå óýãêñéóç ìå ôç äñáóôéêÞ ìåßùóç Þ êáôÜñãçóç ôïõêáðíßóìáôïò, ç áðïìÜêñõíóç üëùí ôùí äõíçôéêþíðåñéâáëëïíôéêþí êáñêéíïãüíùí ïýôå åßíáé ðñáêôé-êÜ åöéêôÞ, áëëÜ ïýôå êáé èá Ý÷åé óçìáíôéêÞ åðß-äñáóç óôç óõíïëéêÞ åðßðôùóç ôïõ ÊÐ.

� Ïé ðåñéâáëëïíôéêÝò ðáñåìâÜóåéò ãéá ôçí áðïìÜ-êñõíóç êáñêéíïãüíùí ïõóéþí åßíáé ãåíéêÜ äõóêï-ëüôåñåò áðü ôçí ðñïóðÜèåéá ãéá ìåßùóç ôçò Ýêèå-óçò óôïí êáðíü, ðñÝðåé üìùò íá ãßíïíôáé åêåß ðïõõðÜñ÷ïõí óáöåßò åíäåßîåéò (ü÷é ìüíï ãéá êáñêßíï,áëëÜ êáé ãéá Üëëá íïóÞìáôá).

� ÔÝëïò, ìå äåäïìÝíç ôç óõíÝñãåéá ðïõ Ý÷åé ï êá-ðíüò ìå ôá ðåñéâáëëïíôéêÜ êáñêéíïãüíá, èá ìðï-ñïýóáìå íá õðïèÝóïõìå üôé ç áðïìÜêñõíóç ôïõêáðíïý èá êÜíåé êáé ôç âëáðôéêÞ åðßäñáóç ôïõ ðå-ñéâÜëëïíôïò ó÷åôéêÜ ìéêñüôåñç.

SUMMARY

Non-occupational environmental factors and lung cancer

A. Papagiannis

Cigarette smoke is by far the major extrinsic (non-genetic) cause of lung cancer. A small number ofcases of this disease may be due to other environmental factors which act either independently orsynergistically with tobacco smoke. The effect of environmental carcinogens is most obvious inoccupational settings where the responsible substance may occur in relatively high concentrations.However, certain substances may cause carcinogenesis even after non-occupational exposure. Thedetailed study of environmental effects is fraught with methodological problems. However, it is clearthat factors such as radon, arsenic, asbestos, urban pollution, and to a lesser degree socioeconomicconditions and nutrition, may be implicated in a small number of lung cancer cases. The avoidance ofall these factors is not practical, and is not expected to have a significant impact on the incidence oflung cancer as long as the major carcinogen, tobacco, is not effectively controlled. Pneumon 2003,16(1):29-37.

Key words: lung cancer, carcinogenesis, pollution, arsenic, asbestos, radon, nutrition, pet birds,environment


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ÊëéíéêÞ ÌåëÝôç

Óõ÷íüôçôá êáé Ýêâáóç ôïõ ðáéäéêïý âñïã÷éêïýÜóèìáôïò óôçí ðüëç ôçò ËÜñéóáò

Ã. Êñïììýäáò,Ê.É. ÃïõñãïõëéÜíçò,Ð.Á. ÌïëõâäÜò

ÅñãáóôÞñéï Öõóéïëïãßáò (ÌïíÜäá ìåëÝôçò áíáðíåõ-óôéêÞò ëåéôïõñãßáò), Ó÷ïëÞ Åðéóôçìþí Õãåßáò, ÔìÞ-ìá ÉáôñéêÞò, ÐáíåðéóôÞìéï Èåóóáëßáò

ËÝîåéò - êëåéäéÜ: Âñïã÷éêü Üóèìá, ðáéäéêÞ çëé-êßá, ïéêïãÝíåéá, áëëåñãéêÞ ñéíßôéäá, êÜðíéóìá

Áëëçëïãñáößá:Ê.É. ÃïõñãïõëéÜíçò,ÁíáðëçñùôÞò ÊáèçãçôÞòÉáôñéêÞ Ó÷ïëÞ, ÐáíåðéóôÞìéï ÈåóóáëßáòÐáðáêõñéáæÞ 22, ËÜñéóá 41222Ôçë: 2410 627854, Fax: 2410 627853E-mail: [email protected]

ÐÅÑÉËÇØÇ. Óêïðüò áõôÞò ôçò ìåëÝôçò Þôáí íá åîåôáóôïýí çóõ÷íüôçôá ôïõ ðáéäéêïý âñïã÷éêïý Üóèìáôïò óôçí ðüëç ôçò ËÜ-ñéóáò, êáèþò êáé ç åðßäñáóç ôïõ ïéêïãåíåéáêïý ðåñéâÜëëïíôïòêáé ôïõ áôïìéêïý êáé êëçñïíïìéêïý áíáìíçóôéêïý óôçí ðïñåßáôçò íüóïõ. Óå 754 ïéêïãÝíåéåò ìå Ýíá ôïõëÜ÷éóôïí ðáéäß íá ðç-ãáßíåé óå äçìïôéêü âñåöïíçðéáêü óôáèìü óôç ËÜñéóá äéáíåìÞ-èçêå Ýíá óýíôï-ìï åñùôçìáôïëüãéï ðïõ áöïñïýóå óôï Üóèìá.Åêáôüí åßêïóé áðü áõôÝò âñÝèçêå íá Ý÷ïõí ðáéäéÜ ìå óõìðôþìá-ôá áðü ôï áíáðíåõóôéêü óýóôçìá ôïí ðñïçãïýìåíï ÷ñüíï. Ôá ðáé-äéÜ Þôáí 4-8 åôþí êáé ôá åñùôçìáôïëüãéá óõìðëçñþèçêáí áðüôïõò ãïíåßò ôïõò. Óôéò ïéêïãÝíåéåò áõôÝò äéáíåìÞèçêå ôï åñùôç-ìáôïëüãéï ôçò öÜóçò 1 ôçò ìåëÝôçò ISAAC (International Studyof Asthma and Allergy in Childhood), êáèþò êáé Ýíá åñùôçìáôï-ëüãéï ðïõ åîÝôáæå ôçí êïéíùíéêïïéêïíïìéêÞ êáôÜóôáóç ôùí ãï-íéþí, ôï ðåñéâÜëëïí êáôïéêßáò êáé ôéò êáðíéóôéêÝò óõíÞèåéåò.ÅâäïìÞíôá ïéêïãÝíåéåò ôåëéêÜ åß÷áí Ýíá áóèìáôéêü ðáéäß. Äýï÷ñüíéá áñãüôåñá, ïé 66 áðü ôéò 70 ïéêïãÝíåéåò åðáíáîéïëïãÞèç-êáí üóïí áöïñÜ ôçí ðïñåßá ôïõ Üóèìáôïò ôïõ ðáéäéïý, ÷ñçóéìï-ðïéþíôáò Ýíá óýíôïìï åñùôçìáôïëüãéï âáóéóìÝíï óôï ISAAC. Çóõ÷íüôçôá ôïõ Üóèìáôïò áíåñ÷üôáí óôï 9,3%, åíþ ç óõ÷íüôçôáôùí åðåéóïäßùí ìåéùíüôáí ìå ôçí ðñüïäï ôçò çëéêßáò. Ç ðëåéï-øçößá ôùí ðáéäéþí åß÷å Þðéï Üóèìá. ÁëëåñãéêÞ ñéíßôéäá âñÝèçêåóôï 31,4%, åíþ Ýêæåìá óôï 14,2%. Ç áëëåñãéêÞ ñéíßôéäá êáé åðé-ðåöõêßôéäá óõó÷åôéæüôáí ìå ôéò êñßóåéò Üóèìáôïò äýï ÷ñüíéáìåôÜ. Ôï êÜðíéóìá ôùí ãïíÝùí äåí óõíäõÜóôçêå ìå ôá åðåéóüäéáôïõ Üóèìáôïò. Ôá åõñÞìáôá áõôÜ äåß÷íïõí ôïí éäéáßôåñï ñüëï ôïõéóôïñéêïý áôïðßáò óôçí åîÝëéîç ôïõ Üóèìáôïò êáé åðéâåâáéþíïõíôç öèßíïõóá ðïñåßá ôçò óõ÷íüôçôáò ôùí åðåéóïäßùí ìå ôçí çëé-êßá. Ðíåýìùí 2003, 16(1):38-48.


ÅÉÓÁÃÙÃÇ

Ôï Üóèìá åßíáé ìéá áðü ôéò ðéï óçìáíôéêÝò áóèÝ-íåéåò ôçò ðáéäéêÞò çëéêßáò óôéò áíåðôõãìÝíåò ÷þñåò1-3.Ç óõ÷íüôçôá ôïõ Üóèìáôïò êõìáßíåôáé áðü 5 Ýùò 20%ðáãêïóìßùò, äéáöÝñåé óçìáíôéêÜ áðü ðåñéï÷Þ óå ðå-ñéï÷Þ êáé Ý÷åé áõîçèåß óçìáíôéêÜ ôá ôåëåõôáßá 30 ÷ñü-íéá4,5. Ôï ðåñéâÜëëïí óôï ïðïßï ìåãáëþíåé ôï ðáéäßóõíäÝåôáé ìå ôçí ðïñåßá ôïõ âñïã÷éêïý Üóèìáôïò. ÌéáóåéñÜ áðü ðáñáìÝôñïõò, üðùò ïé ëïéìþîåéò óôçí ðñþé-ìç ðáéäéêÞ çëéêßá, ç ïéêéáêÞ óêüíç, ç áôìïóöáéñéêÞñýðáíóç, ôï êÜðíéóìá, åíåñãçôéêü êáé ðáèçôéêü, ôïêëçñïíïìéêü êáé ôï áôïìéêü áíáìíçóôéêü, ðáßæïõíñüëï óôçí åîÝëéîç ôçò íüóïõ6,7. Ôï éóôïñéêü áôïðßáòêáé ôï ïéêïãåíåéáêü éóôïñéêü Üóèìáôïò åðéâáñýíïõíôçí ðñüãíùóç. ÌåôÜ ôçí åöçâåßá ðáñáôçñåßôáé óç-ìáíôéêÞ ýöåóç ôùí óõìðôùìÜôùí óôç ìåãÜëç ðëåéï-øçößá ôùí ðåñéóôáôéêþí. Ï óêïðüò áõôÞò ôçò ìåëÝôçòÞôáí íá åêôéìçèåß ç óõ÷íüôçôá ôïõ Üóèìáôïò óôçí ðüëçôçò ËÜñéóáò êáé íá åîåôáóôåß ç åðßäñáóç ôïõ êëçñï-íïìéêïý êáé áôïìéêïý áíáìíçóôéêïý óôçí ðïñåßá ôçòíüóïõ.

ÕËÉÊÏ ÊÁÉ ÌÅÈÏÄÏÓ

Óå 863 ïéêïãÝíåéåò ìå Ýíá ôïõëÜ÷éóôïí ðáéäß íáðçãáßíåé óå äçìïôéêü âñåöïíçðéáêü óôáèìü óôç ËÜ-ñéóá äéáíåìÞèçêå Ýíá óýíôïìï åñùôçìáôïëüãéï ðïõáöïñïýóå óôï Üóèìá. Ç Ýñåõíá Ýëáâå ÷þñá ôï 1998êáé ðåñéëÜìâáíå êáé ôïõò 7 äçìïôéêïýò âñåöïíçðéá-êïýò óôáèìïýò ðïõ ëåéôïõñãïýí óôçí ðüëç. Åðôáêü-óéåò åâäïìÞíôá ôÝóóåñéò ïéêïãÝíåéåò ôåëéêÜ áíôáðï-êñßèçêáí êáé 120 áðü áõôÝò âñÝèçêå íá Ý÷ïõí ôïõëÜ-÷éóôïí Ýíá ðáéäß ìå óõìðôþìáôá áðü ôï áíáðíåõóôé-êü óýóôçìá ôïí ðñïçãïýìåíï ÷ñüíï. ÐñïêåéìÝíïõ íááðïêëåéóôïýí ôá øåõäþò áñíçôéêÜ ðåñéóôáôéêÜ, ùòðáéäéÜ ìå åí äõíÜìåé Üóèìá èåùñÞèçêáí üóá åß÷áíêáé ôçí ðáñáìéêñÞ õðüíïéá õðïôñïðéÜæïõóáò áíá-ðíåõóôéêÞò íüóïõ, üðùò ðñïÝêõøå áðü ôá åñùôçìá-ôïëüãéá. Ôá ðáéäéÜ Þôáí 4-8 åôþí êáé ôá åñùôçìáôï-ëüãéá óõìðëçñþèçêáí áðü ôïõò ãïíåßò ôïõò. Ôï åñù-ôçìáôïëüãéï ðïõ ÷ñçóéìïðïéÞèçêå ó� áõôÞ ôçí áñ÷éêÞöÜóç ôçò Ýñåõíáò åêðïíÞèçêå áðü ôï åñãáóôÞñéï Öõ-óéïëïãßáò ôçò ÁíáðíïÞò ìå óôü÷ï ôç ìåãáëýôåñç äõ-íáôÞ åõáéóèçóßá óôç óõëëïãÞ ôùí óôïé÷åßùí áðü ôïõò

âñåöïíçðéáêïýò óôáèìïýò (âëÝðå ÐáñÜñôçìá). Óå ðå-ñßðôùóç ðïõ äåí áíáöÝñïíôáí óõìðôþìáôá ðïõ íáãåííïýí êÜðïéá õðïøßá ãéá Üóèìá, åëÞöèçóáí õðü-øéí ôá öÜñìáêá ðïõ êáôÜ êáéñïýò åß÷áí ÷ñçóéìïðïéç-èåß áðü ôá ðáéäéÜ. ÅÜí áõôÜ ðáñÝðåìðáí óå Üóèìá,ôüôå ôá ðáéäéÜ óõìðåñéåëÞöèçóáí óôï äåýôåñï óôÜ-äéï ôçò ìåëÝôçò. Áðü áõôÝò ôéò 120 ïéêïãÝíåéåò æçôÞ-èçêå íá óõìðëçñþóïõí ôï åñùôçìáôïëüãéï ISAAC(âëÝðå ÐáñÜñôçìá) êáèþò êáé Ýíá åñùôçìáôïëüãéïðïõ áöïñïýóå óôï ðåñéâÜëëïí ôïõ óðéôéïý êáé ôçí êïé-íùíéêïïéêïíïìéêÞ êáôÜóôáóç, ìå óêïðü íá ðñïêýøåéìéá áêñéâÞò åêôßìçóç ôçò óõ÷íüôçôáò ôïõ Üóèìáôïòêáé Üëëùí áëëåñãéêþí ðáèÞóåùí óôçí ðüëç ôçò ËÜñé-óáò. ÅâäïìÞíôá ïéêïãÝíåéåò ôåëéêÜ åß÷áí Ýíá áóèìá-ôéêü ðáéäß. Ãéá Ýíáí åðéðëÝïí Ýëåã÷ï, ïé ãïíåßò ñùôÞ-èçêáí åÜí ãíþñéæáí ôç äéÜãíùóç ´´Üóèìá´´ ãéá ôï ðáé-äß ôïõò, åíþ ÷ñçóéìïðïéÞèçêå ãéá ôï óêïðü áõôü êáéôï âéâëéÜñéï õãåßáò ôïõ ðáéäéïý. Ôï åñùôçìáôïëüãéïISAAC (International Study of Asthma and Allergy inAsthma) äçìéïõñãÞèçêå ôï 1991 ìå óêïðü íá ìåãéóôï-ðïéçèïýí ïé ãíþóåéò ìáò ðÜíù óôçí åðéäçìéïëïãßá ôïõÜóèìáôïò êáé ôùí áëëåñãéêþí ðáèÞóåùí 3,8. Ç ìåëÝôçISAAC ôõã÷Üíåé äéåèíïýò áíáãíþñéóçò êáé áðïôåëåß-ôáé áðü 3 öÜóåéò. Ó� áõôÝò åðé÷åéñåßôáé íá ìåëåôçèïýíäéåèíþò êáé óõíôïíéóìÝíá ç óõ÷íüôçôá ôùí áëëåñãé-êþí ðáèÞóåùí (Üóèìá, áëëåñãéêÞ ñéíßôéäá, Ýêæåìá),íá åîåôáóôåß ç åîÝëéîÞ ôïõò óôï ÷ñüíï êáé íá ãßíïõíóõãêñßóåéò áíÜìåóá óôéò äéÜöïñåò ÷þñåò. Ç öÜóç 1åß÷å ùò óôü÷ï ôçí åêôßìçóç ôçò óõ÷íüôçôáò ôïõ Üóèìá-ôïò óå äéÜöïñåò ÷þñåò. Ç öÜóç 2, ç ïðïßá îåêßíçóåôï 1998 êáé âñßóêåôáé óå åîÝëéîç, ó÷åäéÜóôçêå ðñï-êåéìÝíïõ íá ãßíïõí óõãêñéôéêÝò ìåëÝôåò ôçò áóèÝíåéáòêáé ôùí ðáñáãüíôùí êéíäýíïõ. ÐåñéëáìâÜíåé ôï âá-óéêü åñùôçìáôïëüãéï, áëëÜ êáé Üëëåò óõìðëçñùìáôé-êÝò åñùôÞóåéò, äåñìáôéêÝò äïêéìáóßåò ãéá áôïðßá, ìå-ëÝôç ôçò âñïã÷éêÞò õðåñáíôéäñáóôéêüôçôáò, ìåëÝôçäåéãìÜôùí áßìáôïò ãéá IgE ïñïý êáé ãåíåôéêÞ áíÜëõ-óç. Óôç öÜóç 3 èá ìåëåôçèåß ç åîÝëéîç ôïõ Üóèìáôïò,ôçò áëëåñãéêÞò ñéíßôéäáò êáé ôïõ åêæÝìáôïò ìÝóá óôï÷ñüíï óôéò äéÜöïñåò ÷þñåò êáé èá åðé÷åéñçèåß íá óõí-äõáóôåß ç êáôÜ ðåñßðôùóç åîÝëéîç ôçò íüóïõ ìå ôéòðåñéâáëëïíôéêÝò óõíèÞêåò. Ôï åñùôçìáôïëüãéï ôçò öÜ-óçò 1 ìå ìåñéêÝò ôñïðïðïéÞóåéò Þôáí áõôü ðïõ ÷ñçóé-ìïðïéÞèçêå êáé óôçí ðáñïýóá ìåëÝôç. Ôï åñùôçìáôï-ëüãéï áõôü ðåñéëáìâÜíåé 3 ìÝñç. Ôï ðñþôï ìÝñïò áöï-


ñÜ óôï Üóèìá, ôï äåýôåñï óôçí ýðáñîç áëëåñãéêÞò ñé-íßôéäáò êáé ôï ôñßôï óôçí ðáñïõóßá åêæÝìáôïò. ÔïÌÝñïò É ðåñéëáìâÜíåé 8 åñùôÞóåéò, ôï ÌÝñïò ÉÉ 6 êáéôï ÌÝñïò ÉÉÉ 7. Óôï ôñïðïðïéçìÝíï åñùôçìáôïëüãéï(MÝñïò É) ðïõ ÷ñçóéìïðïéÞèçêå óôçí ðáñïýóá ìåëÝ-ôç óõìðåñéåëÞöèçóáí 20 åñùôÞóåéò.

Ôï åñùôçìáôïëüãéï ðïõ áöïñïýóå óôçí êïéíùíé-êïïéêïíïìéêÞ êáôÜóôáóç ôùí ãïíÝùí äéáíåìÞèçêå óôïßäéï öõëëÜäéï, ìáæß ìå ôéò åñùôÞóåéò ôïõ ISAAC ùòåéóáãùãÞ. ÑùôÜ ãéá ôéò ãñáììáôéêÝò ãíþóåéò ôùí ãï-íÝùí êáé ôï åðÜããåëìÜ ôïõò. ÅîåôÜæåé ôéò óõíèÞêåòóôï ÷þñï ðïõ æïõí ôá ìÝëç ôçò ïéêïãÝíåéáò, ôéò êáðíé-óôéêÝò óõíÞèåéåò ôùí ãïíÝùí, áëëÜ êáé ôéò áèëçôéêÝòäñáóôçñéüôçôåò ôïõ ðáéäéïý. Ùò âÜóç ãé� áõôü ôï åñù-ôçìáôïëüãéï, ÷ñçóéìïðïéÞèçêå áíôßóôïé÷ï åñùôçìá-ôïëüãéï áðü ôçí ÐáéäéáôñéêÞ ÊëéíéêÞ ôïõ Ðáíåðéóôç-ìßïõ Éùáííßíùí ãéá ôïí ðñïëçðôéêü Ýëåã÷ï ôçò áíá-ðíåõóôéêÞò ëåéôïõñãßáò ôùí ìáèçôþí óôá ÄçìïôéêÜó÷ïëåßá êáôÜ ôá Ýôç 1996-97.

Äýï ÷ñüíéá áñãüôåñá Ýãéíå ìéá åðáíáîéïëüãçóç(follow-up) ôùí ïéêïãåíåéþí áõôþí. ×ñçóéìïðïéÞèç-êå Ýíá åñùôçìáôïëüãéï ãéá ôï Üóèìá âáóéóìÝíï óôïISAAC áëëÜ ðéï óýíôïìï êáé åðéêåíôñùìÝíï óôá óôïé-÷åßá ðïõ åíäéÝöåñáí óôçí ðáñáêïëïýèçóç ôùí ïéêï-ãåíåéþí. Ï áñéèìüò ôùí êñßóåùí, ï áñéèìüò ôùí åéóá-ãùãþí óôá íïóïêïìåßá êáé ç ôõ÷üí áëëáãÞ óôéò êá-ðíéóôéêÝò óõíÞèåéåò Þôáí ôá êýñéá óçìåßá. Ôï åñùôç-ìáôïëüãéï ðïõ ÷ñçóéìïðïéÞèçêå óôçí åðáíáîéïëüãç-óç (follow-up) ôùí áóèåíþí Þôáí ôï ÌÅÑÏÓ É ôïõISAAC, ÷ùñßò ôéò åñùôÞóåéò 1, 8-10, 15-20, ïé ïðïßåòêáé áíáöÝñïíôáé óôçí áíáãíþñéóç ôçò íüóïõ. Ôá åñù-ôçìáôïëüãéá óõìðëçñþèçêáí ìåôÜ áðü ôçëåöùíéêÞåðéêïéíùíßá ìå ôéò ïéêïãÝíåéåò. Áðü ôï áñ÷éêü äåßãìáôùí 70 ïéêïãåíåéþí, 4 ïéêïãÝíåéåò åß÷áí áëëÜîåé ôüðïäéáìïíÞò êáé äåí Þôáí åýêïëï íá åíôïðéóôïýí. Ôï ôå-ëéêü äåßãìá ðïõ ðåñéåëÞöèç ó� áõôü ôï óôÜäéï ôçò ìå-ëÝôçò áðïôåëåßôï áðü 66 ïéêïãÝíåéåò.

á. Êùäéêïðïßçóç: Ïé ðëçñïöïñßåò ïé ó÷åôéêÝò ìåôïí áñéèìü ôùí áôüìùí óôçí ïéêïãÝíåéá (áäÝëöéá, ôõ-÷üí çëéêéùìÝíá Üôïìá óôï óðßôé) êáèþò êáé ôïõ ïéêï-ãåíåéáêïý éóôïñéêïý åëÞöèçóáí áðü ôï óêÝëïò ôïõåñùôçìáôïëïãßïõ ðïõ áöïñïýóå óôïõò ãïíåßò. Ç êïé-íùíéêïïéêïíïìéêÞ êáôÜóôáóç, åêôéìÞèçêå ìå âÜóç ôçìüñöùóç êáé ôï åðÜããåëìá ôùí ãïíÝùí. Ç áêáäçìáú-êÞ ìüñöùóç ðñïóäéïñßóôçêå óå ôñßá åðßðåäá èåùñþ-

íôáò ôï ãõìíÜóéï êáé ôï ëýêåéï ùò åíéáßá ïíôüôçôá,áöïý óôçí ÅëëÜäá ôéò 2 ôåëåõôáßåò äåêáåôßåò ïé ðå-ñéóóüôåñïé ìáèçôÝò óõíå÷ßæïõí ôéò óðïõäÝò óôï ëýêåéï.Ùò áíþôåñç/ áíþôáôç åêðáßäåõóç èåùñÞèçêáí ïé ìåôÜôï ëýêåéï óðïõäÝò, äéÜñêåéáò Üíù ôùí äýï åôþí. Çðõêíüôçôá ôùí áôüìùí ðïõ ìÝíïõí óôï óðßôé õðïëïãß-óôçêå äéáéñþíôáò ôïí áñéèìü ôùí áôüìùí ìå ôïí áñéè-ìü ôùí äùìáôßùí (÷áìçëÞ , ìÝôñéá 1-2, õøçëÞ). ÔÝëïò,óõãêñßèçêáí äåäïìÝíá ãéá ôéò êáðíéóôéêÝò óõíÞèåéòìå Ýìöáóç óôï êÜðíéóìá ìÝóá óôï óðßôé.

â. Åðåîåñãáóßá: Ôá äåäïìÝíá åîåôÜóôçêáí ìå ôç÷ñÞóç ôïõ Pearson êáé ôç äéüñèùóç óõíÝ÷åéáò ôïõ Ya-tes, üðïõ Þôáí áðáñáßôçôç. ÅñåõíÞèçêå ç ó÷Ýóç áíÜ-ìåóá óôïõò ðáñÜãïíôåò ôùí ãïíÝùí êáé ôçí åîÝëéîçôùí áóèìáôéêþí êñßóåùí äýï ÷ñüíéá ìåôÜ. Ïé ðáñÜ-ìåôñïé ðïõ åîåôÜóôçêáí Þôáí ôï öýëï ôïõ ðáéäéïý, ôïéóôïñéêü ôùí ãïíÝùí ãéá ôï Üóèìá, ç êïéíùíéêïïéêï-íïìéêÞ êáôÜóôáóç ôçò ïéêïãÝíåéáò, ç Ýêèåóç óôï êÜ-ðíéóìá ôùí ãïíéþí, ôï éóôïñéêü ôïõ ðáéäéïý ãéá Ýêæå-ìá Þ áëëåñãéêÞ ñéíßôéäá, ç ðõêíüôçôá ôùí áôüìùí óôïóðßôé êáé ï áñéèìüò ôùí ìåãáëýôåñùí áäåëöþí. Ôïåðßðåäï óôáôéóôéêÞò óçìáíôéêüôçôáò Þôáí ôï 0,05. ÇóôáôéóôéêÞ åðåîåñãáóßá Ýãéíå ìå ôï ðñüãñáììá SPSSfor Windows, Ýêäïóç 7,5.

ÁÐÏÔÅËÅÓÌÁÔÁ

Ôï õëéêü ôçò Ýñåõíáò áðïôåëïýóáí ïé 70 ïéêïãÝ-íåéåò ìå Ýíá áóèìáôéêü ðáéäß ç êÜèå ìßá. Ôá åðéäç-ìéïëïãéêÜ ÷áñáêôçñéóôéêÜ ôïõ äåßãìáôïò öáßíïíôáéóôïí ðßíáêá 1. Ç óõ÷íüôçôá ôïõ Üóèìáôïò áíÞëèå ôå-ëéêÜ óôï 9,3% (70/754). Ðïóïóôü 45,7% ôùí ðáéäéþíÞôáí áãüñéá êáé 54,3% êïñßôóéá. Ç ìÝóç çëéêßá ôùíðáéäéþí Þôáí 5,9 Ýôç. Ðïóïóôü 68,6% ôùí ðáôÝñùí êáé58,5% ôùí ìçôÝñùí Þôáí áíþôåñçò Þ áíþôáôçò áêá-äçìáúêÞò ìüñöùóçò (ðßíáêáò 1). Ç ðëåéïøçößá ôùíðáéäéþí ðáñïõóßáæáí Þðéï Üóèìá (ðßíáêáò 2). Ðïóï-óôü 75,7% ôùí ðáéäéþí åß÷áí ìßá êñßóç ôïí ðñïçãïý-ìåíï ÷ñüíï êáé ìüíï ðïóïóôü 2,8% åß÷å ôñåéò êñßóåéòôï ÷ñüíï. ¸êæåìá áíáöÝñèçêå óôï 14,2% ôùí ðåñé-ðôþóåùí êáé áëëåñãéêÞ ñéíßôéäá óôï 31,4% ôùí ðåñé-ðôþóåùí (ðßíáêáò 2). ¼óïí áöïñÜ ôçí êëçñïíïìéêü-ôçôá, ôï 38,6% áíáöÝñåé Ýíáí ôïõëÜ÷éóôïí óõããåíÞ á´Þ â´ âáèìïý ìå âñïã÷éêü Üóèìá (ðßíáêáò 3). Äýï ÷ñü-íéá ìåôÜ ç óõ÷íüôçôá åðáíåìöÜíéóçò ôùí óõìðôùìÜ-


ÓÕÆÇÔÇÓÇ

Ç óõ÷íüôçôá ôïõ Üóèìáôïò ðïõ ðñïóäéïñßóôçêåóôçí ðáñïýóá ìåëÝôç Þôáí 9,3%, ôéìÞ êïíôÜ óå åêåßíçðïõ áíáöÝñïõí äéåèíåßò ìåëÝôåò ôá ôåëåõôáßá ÷ñüíéá3-5. Ç óõ÷íüôçôá ôïõ ðáéäéêïý Üóèìáôïò óôçí Åõñþðçêõìáßíåôáé ìåôáîý 7% êáé 11%. Óôçí ÅëëÜäá êáé óýì-öùíá ìå ôá áðïôåëÝóìáôá ôçò ðñþôçò ðáíåëëÞíéáòìåëÝôçò ãéá ôï ðáéäéêü Üóèìá óôç ÷þñá ìáò (1988) çóõ÷íüôçôá ôïõ ðáéäéêïý Üóèìáôïò ãéá ðáéäéÜ çëéêßáò7-8 åôþí ðñïóäéïñßæåôáé óôï 7,3% ðåñßðïõ9. Óôç Èåó-óáëßá ðñüóöáôåò Ýñåõíåò áíåâÜæïõí ôá ðïóïóôÜ áõôÜóôï 8%10. Óôçí Ôïõñêßá ôï ðïóïóôü áõôü Þôáí 9,8%åíþ ôïõ óõñéãìïý Þôáí 15,1%11. Óôçí Áããëßá ç óõ÷íü-ôçôá ôïõ óõñéãìïý Ýöôáíå ôï 33% êáé ôïõ Üóèìáôïòôï 20%12. ¼óïí áöïñÜ ôï êáôÜ ðüóï ïé ãïíåßò ÞôáíåíÞìåñïé ãéá ôçí áóèÝíåéá ôïõ ðáéäéïý ôïõò âñÝèçêåüôé ðåñßðïõ 70% ôùí ãïíéþí ãíþñéæáí üôé ôï ðáéäß ôïõòåß÷å Üóèìá, åíþ ïé õðüëïéðïé áíÝöåñáí ôïõò üñïõòáóèìáôéêÞ âñïã÷ßôéäá, óðáóôéêÞ âñïã÷ßôéäá Þ áëëåñ-ãéêÞ âñïã÷ßôéäá, ÷ùñßò íá ãíùñßæïõí üôé ïé üñïé åßíáéóõíþíõìïé ôïõ Üóèìáôïò.

Ç óõ÷íüôçôá ôüóïí ôïõ óõñéãìïý, üóïí êáé ôïõÜóèìáôïò Ý÷ïõí áõîçèåß óôáèåñÜ ôá ôåëåõôáßá 30 ÷ñü-íéá. ÂñÝèçêå üôé ç áýîçóç óôç óõ÷íüôçôá ôïõ Üóèìá-ôïò Þôáí ðïëý ìåãáëýôåñçò åêåßíçò ôïõ óõñéãìïý13,14.Áõôü åíéó÷ýåé ôçí õðüèåóç üôé Ýíáò óçìáíôéêüò ëüãïòãéá ôçí áýîçóç ôçò óõ÷íüôçôáò åßíáé ìåôáîý Üëëùí çïëïÝíá êáé ðéï óõ÷íÞ áíáãíþñéóç ôçò íüóïõ þò�Üóèìá�, óå áíôßèåóç ìå üñïõò üðùò �áóèìáôïåéäÞ�

Ðßíáêáò 2. ×áñáêôçñéóôéêÜ ôùí áóèìáôéêþí ðáéäéþí.

ÐáñÜìåôñïé ÌÝóç ôéìÞ Ó÷üëéá

ÁóèìáôéêÝò êñßóåéò ôïí ôåëåõôáßï ÷ñüíï 1 53 (74,3%) åß÷å ìßá êñßóç6 (8,6%) åß÷å äýï êñßóåéò2 (2,8%) åß÷å ôñåéò êñßóåéò

ÌÝñåò áðïõóßáò áðü ôï ó÷ïëåßï 4 53 (75,7%) ëéãüôåñï áðü 10 çìÝñåòÅðéóêÝøåéò óôï ãéáôñü 2 62 (88,6%) ëéãüôåñï áðü 5 öïñÝòÅéóáãùãÝò óôï Íïóïêïìåßï 0 53 (75,7%) êáìßá

11 (15,7%) ìßá

¢ëëåò áóèÝíåéåò Í %

ÁëëåñãéêÞ ñéíßôéäá 22 31,4¸êæåìá 10 14,2AëëåñãéêÞ ñéíßôéäá êáé/Þ Ýêæåìá 27* 38,5

*5 ðáéäéÜ åß÷áí áëëåñãéêÞ ñéíßôéäá êáé Ýêæåìá

Ðßíáêáò 1. ÄçìïãñáöéêÜ ÷áñáêôçñéóôéêÜ ôïõ äåßãìáôïò

ËÜñéóá 1998

Í Ì SD %

Çëéêßá ôïõ Ðáéäéïý (ìÝóç ôéìÞ) 70 5,9 1,17Çëéêßá ôïõ ÐáôÝñá 70 39 4,30Çëéêßá ôçò ìçôÝñáò 70 33,9 4,61Öýëï (áãüñéá) 32 45,7

Áñéèìüò áäåëöþí0 17 24,31 41 58,62 9 12,93 3 4,3

Ìüñöùóç ðáôÝñá (÷ñüíéá)<6 3 4,3

6-14 19 27,1>14 48 68,6

Müñöùóç ìçôÝñáò (÷ñüíéá)<6 1 1,4

6-14 28 40,1>14 41 58,5

ÊÜðíéóìá ìçôÝñáò 28 40ÊÜðíéóìá ðáôÝñá 42 60

ôùí áíåñ÷üôáí óå 9,1% (ðßíáêáò 4) Ïé êñßóåéò äåí îå-ðÝñáóáí ôç ìßá ôï ÷ñüíï, åíþ óå êáìéÜ ðåñßðôùóç äåí÷ñåéÜóôçêå åéóáãùãÞ óå íïóïêïìåßï. Ïé áóèìáôéêÝòêñßóåéò äýï ÷ñüíéá ìåôÜ óõó÷åôßóôçêáí óôáôéóôéêÜóçìáíôéêÜ ìüíï ìå ôï éóôïñéêü áëëåñãéêÞò ñéíßôéäáòêáé åðéðåöõêßôéäáò (ðõñåôüò åê ÷üñôïõ) (ðßíáêáò 5).


óå 12%, êáèþò êáé óôïí ðõñåôü åê ÷üñôïõ áðü 3% óå12%, ãåãïíüò ðïõ äåß÷íåé ôç ãåíéêüôåñç ôÜóç áýîç-óçò óôéò ðåñéðôþóåéò ìå áôïðßá16. ¼óïí áöïñÜ óôçíêëçñïíïìéêüôçôá ôïõ âñïã÷éêïý Üóèìáôïò, ôá ðïóï-óôÜ èåôéêïý ïéêïãåíåéáêïý éóôïñéêïý êõìáßíïíôáé áðü30% Ýùò 60%17. Ç ðéï óçìáíôéêÞ ðáñÜìåôñïò åßíáé ôïéóôïñéêü Üóèìáôïò êáé áôïðßáò ôùí ãïíÝùí êáé åéäé-êÜ ôçò ìçôÝñáò6. ÌåëÝôåò óå äéäýìïõò Ýäåéîáí üôé ôáåðßðåäá IgE ôïõ ïñïý óå ðáéäéÜ êáé åíÞëéêåò Ý÷ïõíãåíåôéêÞ ó÷Ýóç, åíþ Üëëåò ìåëÝôåò äåß÷íïõí ìéá ãåíå-ôéêÞ ó÷Ýóç ãéá ôç âñïã÷éêÞ õðåñáíôéäñáóôéêüôçôá,áêüìá êáé üôáí äåí õðÜñ÷åé êëéíéêÜ Ýêäçëç íüóïò18,19.

¼óïí áöïñÜ óôçí åðßðôùóç ôïõ âñïã÷éêïý Üóèìá-ôïò, áëëÜ êáé ôçí åîÝëéîÞ ôïõ óôçí ðáéäéêÞ çëéêßá, ëß-ãåò åßíáé ïé ìåëÝôåò ðïõ áó÷ïëïýíôáé ìå ôï èÝìá áõôü.Óôçí ðáíåèíéêÞ ìåëÝôç ôçò ÌåãÜëçò Âñåôáíßáò, ç åôÞ-óéá åðßðôùóç ôïõ Üóèìáôïò ãéá ôéò çëéêßåò 7, 11, 16, 23Ýôç Þôáí 2,6%, 1,1%, 0,7% êáé 0,8% áíôßóôïé÷á20. ÇãåíéêÞ åíôýðùóç åßíáé üôé ç åðßðôùóç ôïõ Üóèìáôïòåßíáé ìåãÜëç óôçí ðñþéìç ðáéäéêÞ çëéêßá êáé óôç óõ-íÝ÷åéá åëáôôþíåôáé êáèþò ôï ðáéäß ìðáßíåé óôçí åöç-âåßá. Ç ðëåéïøçößá ôùí íçðßùí êáé ôùí ðáéäéþí ðñï-ó÷ïëéêÞò çëéêßáò ðáñïõóéÜæïõí ðáñïäéêÜ åðåéóüäéáóõñéãìïý, ÷ùñßò ùóôüóï áõôü íá óçìáßíåé üôé Ý÷ïõíáõîçìÝíï êßíäõíï ãéá ôçí áíÜðôõîç Üóèìáôïò Þ áë-ëåñãéþí áñãüôåñá óôç æùÞ ôïõò. Ùò ãåíéêüò êáíüíáòéó÷ýåé üôé ìå ôçí åßóïäï óôçí åöçâåßá ðáñáôçñåßôáéáîéüëïãç ýöåóç ôùí åðåéóïäßùí. Ðáñüëá áõôÜ, ïéêáêÝò êëéìáôïëïãéêÝò óõíèÞêåò, ïé óõ÷íÝò éïãåíåßòëïéìþîåéò êáé ç áôïðéêÞ ðñïäéÜèåóç äçìéïõñãïýíðñüóöïñï Ýäáöïò ãéá ôçí åðéìïíÞ ôùí êñßóåùí. Óôçíðáñïýóá ìåëÝôç ç óõ÷íüôçôá ôïõ Üóèìáôïò ðáñïõóéÜ-æåôáé áõîçìÝíç óå óýãêñéóç ìå ðñïãåíÝóôåñç Ýñåõíáóôïí Åëëáäéêü ÷þñï êáé 15% ðéï õøçëÞ óå ó÷Ýóç ìåÜëëç ðñïò 5åôßáò Ýñåõíá óôï ÷þñï ôçò Èåóóáëßáò10.Ôï åýñçìá áõôü åßíáé óýìöùíï ìå ôéò áõîçôéêÝò ôÜ-óåéò ðïõ ðáñïõóéÜæåé ôï Üóèìá äéåèíþò ôá ôåëåõôáßá÷ñüíéá.

Ç óõ÷íüôçôá ôùí áóèìáôéêþí åðåéóïäßùí 2 ÷ñü-íéá ìåôÜ ôçí ðñþôç åðáíåêôßìçóç áíåñ÷üôáí óôï 9,1%.Ç óïâáñüôçôá ôùí åðåéóïäßùí Þôáí ìéêñüôåñç, áöïýóå êáìéÜ ðåñßðôùóç äåí áíáöÝñèçêå åéóáãùãÞ óôïíïóïêïìåßï. Ç öèßíïõóá ðïñåßá ôçò óõ÷íüôçôáò åðá-íåìöÜíéóçò ôùí êñßóåùí óõìöùíåß ìå ôç ãåíéêüôåñçåõíïúêÞ ðñüãíùóç ôïõ Üóèìáôïò êáèþò ôï ðáéäß ìå-

Ðßíáêáò 3. Óõ÷íüôçôá ôçò åìöÜíéóçò ôïõ âñïã÷éêïý Üóèìá-ôïò óå ìÝëç ïéêïãåíåéþí ìå áóèìáôéêÜ ðáéäéÜ.

ÌÝëïò ïéêïãÝíåéáòìå âñïã÷éêü Üóèìá Áñéèìüò áôüìùí Ðïóïóôü

ÌçôÝñá 6 8,6%ÐáôÝñáò 4 5,7%Áäåëöüò 6 8,6%ÃéáãéÜ 6 8,6%Ðáððïýò 5 7,1%Êáíåßò 43 61,4%Óýíïëï 70 100%

Ðßíáêáò 4. ÅîÝëéîç ôïõ Üóèìáôïò 2 ÷ñüíéá ìåôÜ.

90,9 ÷ùñßò óõìðôþìáôá9,1 Þðéá óõìðôþìáôá

Ðßíáêáò 5. ÁëëåñãéêÞ ñéíßôéäá-åðéðåöõêßôéäá êáé áóèìáôé-êÝò êñßóåéò äýï ÷ñüíéá áñãüôåñá.

ÁëëåñãéêÞ ñéíßôéäá ÁóèìáôéêÝò êñßóåéòêáé åðéðåöõêßôéäá 2 ÷ñüíéá ìåôÜ Óýíïëï

Íáé ¼÷é

Íáé 5 17 22¼÷é 1 43 44

Óýíïëï 6 60 66

P < 0,05.

Þ �áëëåñãéêÞ âñïã÷ßôéäá� ðïõ ÷ñçóéìïðïéïýíôáí óôïðáñåëèüí. Åßíáé áëÞèåéá üôé ðáñáôçñïýíôáé ìåãÜëåòäéáöïñÝò óôç óõ÷íüôçôá ôïõ Üóèìáôïò áðü ðåñéï÷Þóå ðåñéï÷Þ, áëëÜ êáé áðü ìåëÝôç óå ìåëÝôç3. Ãéá ôéòäéáöïñÝò ðïõ ðáñáôçñïýíôáé, óå Ýíá âáèìü åõèýíï-íôáé ç äéáöïñåôéêÞ ìåèïäïëïãßá, áëëÜ êáé ôá êñéôÞ-ñéá ðïõ ÷ñçóéìïðïéïýíôáé. Ùóôüóï, öáßíåôáé ðùò ðÝñááðü ôçí áíáãíþñéóç ôçò íüóïõ áõôÞò êáè� áõôÞò êáéôá üðïéá ðñïâëÞìáôá óôç ìåèïäïëïãßá, õðÜñ÷åé êáéðñáãìáôéêÞ áýîçóç ôùí ðåñéóôáôéêþí. Óôï Hong-Kongç óõ÷íüôçôá ôïõ Üóèìáôïò áõîÞèçêå êáôÜ 71% êáéôïõ óõñéãìïý êáôÜ 24% ìÝóá óå ëßãá ÷ñüíéá15. Ðáñü-ìïéá åßíáé ôá åõñÞìáôá êáé óå Üëëåò ìåëÝôåò. Óôçí ðüëçÁìðåñíôÞí ôçò Óêïôßáò ç óõ÷íüôçôá ôïõ óõñéãìïý óôáðáéäéÜ, áõîÞèçêå áðü 10% ôï 1964 óå 20% ôï 1989,åíþ ôï Üóèìá áõîÞèçêå áðü 4% óå 10%. Áýîçóç åðß-óçò óçìåéþèçêå óôá ðåñéóôáôéêÜ ìå Ýêæåìá áðü 6%


ãáëþíåé. Ðáñüìïéá åõñÞìáôá, áðü ðëåõñÜò óõ÷íüôç-ôáò, áëëÜ óå ìåãáëýôåñï âÜèïò ÷ñüíïõ, áíáöÝñïíôáéóå ìåëÝôç óôç ÌåãÜëç Âñåôáíßá êáé óå ðáéäéÜ ðïõðáñáêïëïõèÞèçêáí áðü ôá 7 ìÝ÷ñé ôá 30 ôïõò. Ôï ðï-óïóôü ôùí ðáéäéþí ðïõ åîáêïëïõèïýóáí íá åìöáíß-æïõí åðåéóüäéá óôçí çëéêßá ôùí 7 åôþí Þôáí 18%21.Óôçí ÅëëÜäá êáé óôï ðëáßóéï ôçò ìåëÝôçò ISAAC, ïåðéðïëáóìüò ôïõ Üóèìáôïò óôçí çëéêßá 13-14 åôþí êáéóå äåßãìá 2.561 ðáéäéþí õðïëïãßóôçêå ðåñß ôï 5%, áðüôá ÷áìçëüôåñá ðïóïóôÜ ðáãêïóìßùò3.

Óôïí åðáíÝëåã÷ï ðïõ ðñáãìáôïðïéÞèçêå äýï ÷ñü-íéá ìåôÜ ôçí ðñþôç åêôßìçóç, ïé áóèìáôéêÝò êñßóåéòóõó÷åôßóôçêáí óôáôéóôéêÜ óçìáíôéêÜ ìüíï ìå ôï éóôï-ñéêü áëëåñãéêÞò ñéíßôéäáò. Óôçí ðáñïýóá ìåëÝôç, óåáíôßèåóç ìå Üëëåò ìåëÝôåò, ôï éóôïñéêü åêæÝìáôïò äåóõó÷åôßóôçêå ìå ôçí åðáíåìöÜíéóç ôùí áóèìáôéêþíêñßóåùí10,20,22. Ôüóïí ç áëëåñãéêÞ ñéíßôéäá êáé åðéðå-öõêßôéäá, üóïí êáé ôï éóôïñéêü åêæÝìáôïò ó÷åôßæïíôáéóôåíÜ ìå ôçí åðßðôùóç ôïõ Üóèìáôïò, áëëÜ êáé ôçí åðé-ìïíÞ ôùí óõìðôùìÜôùí óôç äéáäñïìÞ ôçò íüóïõ23,24. ÇáëëåñãéêÞ ñéíßôéäá ìå óõíïäü åðéðåöõêßôéäá (ðõñå-ôüò åê ÷üñôïõ) áõîÜíåé, ùò áôïðéêÞ åêäÞëùóç, êáôÜðïëý ôïí êßíäõíï ãéá ôçí åðéìïíÞ ôùí óõìðôùìÜôùíôïõ Üóèìáôïò ìåôÜ ôçí çëéêßá ôùí 2025. ÃåíéêÜ ôá ðáé-äéÜ ìå áôïðéêÝò åêäçëþóåéò (ðõñåôüò åê ÷üñôïõ, Ýê-æåìá) ðáñïõóéÜæïõí óå áõîçìÝíï ðïóïóôü âñïã÷éêÞõðåñáíôéäñáóôéêüôçôá, åéäéêÜ åêåßíá ðïõ åìöáíßæïõíåõáéóèçóßá óå ðåñéóóüôåñåò áðü ìéá ïìÜäåò áëëåñ-ãéïãüíùí26,27. Ç óïâáñüôçôá, åîÜëëïõ ôçò âñïã÷éêÞòõðåñáíôéäñáóôéêüôçôáò áõîÜíåé áíÜëïãá ìå ôï âáè-ìü ôçò áôïðßáò. Áðü ôçí Üëëç ðëåõñÜ, ç õðï÷þñçóçôùí óõìðôùìÜôùí ôçò áëëåñãéêÞò ñéíßôéäáò ìåôÜ áðüôïðéêÞ ÷ñÞóç êïñôéêïóôåñïåéäþí óõíïäåýåôáé áðüâåëôßùóç ôïõ Üóèìáôïò28. ÃåíéêÜ ï ïéïóäÞðïôå åñåèé-óìüò ôïõ áíþôåñïõ áíáðíåõóôéêïý öáßíåôáé éêáíüò íáðñïêáëÝóåé åðéäåßíùóç ôïõ Üóèìáôïò. Áêüìá êáé çïîåßá Þ ÷ñüíéá ðáñáññéíïêïëðßôéäá ìðïñåß íá ðñï-êáëÝóåé âñïã÷éêÞ õðåñáíôéäñáóôéêüôçôá29. Óôçí ðá-ñïýóá ìåëÝôç, êÜðïéåò Üëëåò ðáñÜìåôñïé, ãíùóôÝò ãéáôç óðïõäáéüôçôÜ ôïõò óôçí Ýíáñîç êáé åîÝëéîç ôïõÜóèìáôïò åß÷áí ìéêñüôåñç óçìáóßá. Ïé êáðíéóôéêÝòóõíÞèåéåò ôùí ãïíéþí êáé ï áñéèìüò ôùí ôóéãÜñùí ðïõêáðíßæïíôáé ìÝóá óôï óðßôé äåí ó÷åôßæïíôáé ìå ôç âá-

ñýôçôá ôïõ Üóèìáôïò êáé ôï ßäéï óõìâáßíåé êáé ìå ôçíêïéíùíéêïïéêïíïìéêÞ êáôÜóôáóç. ¼ðùò ðñïÝêõøåáðü Üëëåò ìåëÝôåò ôï êÜðíéóìá ôçò ìçôÝñáò Ý÷åé éäéáß-ôåñç óçìáóßá åéäéêÜ óôç äéÜñêåéá ôçò åãêõìïóýíçòêáé ôçò ãáëïõ÷ßáò30,32. Ï áñéèìüò ôùí ôóéãÜñùí åßíáéåðßóçò óçìáíôéêüò ìå ôï 1/2 ðáêÝôï íá åßíáé ôï êñßóé-ìï üñéï. ÐÜíôùò, ôï êÜðíéóìá äå öáßíåôáé íá åðçñåÜ-æåé ôçí ðïñåßá ôïõ Üóèìáôïò óôçí üøéìç ðáéäéêÞ çëé-êßá.

Óå áõôÞ ôç ìåëÝôç, äåäïìÝíïõ üôé õðÞñîáí ìüíïäýï ÷ñüíéá ãéá ôçí ðáñáêïëïýèçóç ôùí áññþóôùí,èá ðñÝðåé íá ëçöèïýí õðüøç ìåñéêÝò áêüìá ðáñÜìå-ôñïé êáé ðéèáíÜ óöÜëìáôá. ÅÜí ç äéÜñêåéá ôçò ðáñá-êïëïýèçóçò Þôáí ìåãáëýôåñç, ßóùò íá ðñïÝêõðôáí êÜ-ðïéåò Üëëåò åðéäñÜóåéò. Ôï äåßãìá ôùí áóèåíþí, áíêáé åðéëÝ÷ôçêå ôõ÷áßá áðü ôïõò ìáèçôÝò ôùí äçìïôé-êþí ðáéäéêþí óôáèìþí, ßóùò íá ìçí åßíáé áíôéðñïóù-ðåõôéêü, åíþ ïé ãïíåßò äéáöïñåôéêþí êïéíùíéêïïéêï-íïìéêþí ôÜîåùí ßóùò íá ðñïôéìïýí éäéùôéêïýò óôáè-ìïýò. Áðü ôçí Üëëç ðëåõñÜ, ç áôïðßá ÷ùñßò ôçí áîéï-ëüãçóç åéäéêÞò åõáéóèçôïðïßçóçò, äåí åßíáé åýêïëïíá áîéïëïãçèåß êáôÜ ôçí õðü ìåëÝôç çëéêßá, äåäïìÝ-íçò ôçò óõ÷íüôçôáò ôùí ðñïåîáñ÷ïõóþí ëïéìþîåùí.Ïé áðáíôÞóåéò ôùí ãïíÝùí ðïõ áöïñïýóáí óôï êëç-ñïíïìéêü áíáìíçóôéêü ßóùò íá ìçí Þôáí áîéüðéóôåò.Óõ÷íÜ ôï Üóèìá óõã÷Ýåôáé ìå íüóïõò üðùò ç ÷ñüíéááðïöñáêôéêÞ ðíåõìïíïðÜèåéá Þ ç êáñäéáêÞ áíåðÜñ-êåéá. Åðßóçò, ðïëëïß äåí ãíþñéæáí üôé üñïé üðùò áë-ëåñãéêÞ Þ óðáóôéêÞ âñïã÷ßôéäá åßíáé üñïé óõíþíõìïéôïõ Üóèìáôïò. ÕðÜñ÷åé áêüìá ôï åíäå÷üìåíï óêüðé-ìá íá ìçí äüèçêáí åéëéêñéíåßò áðáíôÞóåéò ëüãù ðñï-êáôÜëçøçò ãéá ôç âáñýôçôá ôçò íüóïõ.

Ç ðáñïýóá ìåëÝôç åß÷å ðñïêáôáñêôéêü ÷áñáêôÞ-ñá. Áí êáé áóöáëÞ óõìðåñÜóìáôá åßíáé äýóêïëï íáåîá÷èïýí, ôá åõñÞìáôÜ ôçò åðéóçìáßíïõí ôï ñüëï ôïõéóôïñéêïý ôçò áôïðßáò óôçí åîÝëéîç ôïõ Üóèìáôïò. Ðá-ñÜëëçëá åðéâåâáéþíïõí ôï ãåãïíüò üôé ç óõ÷íüôçôáôïõ Üóèìáôïò áõîÜíåôáé óôáèåñÜ ôá ôåëåõôáßá ÷ñü-íéá. ÔÝëïò, êáé áõôÞ ç ìåëÝôç äåß÷íåé ôç öèßíïõóá ðï-ñåßá ðïõ áêïëïõèïýí ïé êñßóåéò Üóèìáôïò ìå ôçí ðñüï-äï ôçò çëéêßáò, êáèþò ôï ðáéäß åéóÝñ÷åôáé óôçí åöç-âåßá.


SUMMARY

Frequency and outcome of childhood bronchial asthma in the town of Larissa

Krommydas G, Goulgoulianis KI, Molyvdas PA

The purpose of this study was to estimate the frequency of bronchial asthma in childhood in thetown of Larissa and to assess the possible effects of social status, environmental factors, the child�smedical and family history on the course of the disease. A brief asthma questionnaire was distributedand completed by 754 families with at least one child attending a public day nursery in Larissa. Ofthese, 120 were found to have a child with symptoms consistent with asthma in the past year. Childrenwere 4-8 years old and the questionnaire was completed by their parents. The International Study ofAsthma and Allergy in Childhood (ISAAC)-Phase I questionnaire with additional items referring tothe socio-economic status of the family, indoor environment factors and parental smoking habitswas used. A child with asthma was identified in seventy families. Two years later the course of thedisease was evaluated in 66 of those families, using a modified ISAAC questionnaire. The frequen-cy of bronchial asthma in the study population was 9.3%, with the frequency of asthma attacksdeclining with age. The majority of the children had mild asthma. Allergic rhinitis was found in31.4% and allergic dermatitis (eczema) in 14.2%. Parental smoking was not related to asthmaticattacks. Allergic rhinitis and conjunctivitis were strongly related to asthmatic attacks on reevaluationtwo years later. These results suggest an important role of atopic disease in the course of asthma andconfirm the reports of declining attack frequency with advancing age. Pneumon 2003, 16(1):38-48.

Key words: Bronchial asthma, family, childhood, allergic rhinitis, smoking.

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ÐÁÑÁÑÔÇÌÁÅÑÙÔÇÌÁÔÏËÏÃÉÏ ISAAC (ÔñïðïðïéçìÝíï)

ÂÜëôå óå êýêëï ôç óùóôÞ áðÜíôçóç1. Ïíïìáôåðþíõìï .......................................................................................................................................................................................................................................................................................................2. Ðáôñþíõìï ...............................................................................................................................................................................................................................................................................................................3. Çìåñïìçíßá ãÝííçóçò ............................................................................................................................................................................................................................................................................................4. Äéåýèõíóç êáôïéêßáò ...............................................................................................................................................................................................................................................................................................5. Ó÷ïëåßï .......................................................................................................................................6. ÔÜîç ............................................................................................................................................ ÔìÞìá ..............................................................................................7. ÔçëÝöùíï ...................................................................................................................................8. ´Å÷åôå Üëëá ðáéäéÜ; Íáß ¼÷é

Öýëï Çëéêßá (Ýôç)............................................... ............................................................................................. ............................................................................................. ..............................................

8.1. ÓåéñÜ ãÝííçóçò ôïõ ðáéäéïý

9. ÃñáììáôéêÝò ãíþóåéò ðáôÝñá: 1. Äçìïôéêü 2. ÃõìíÜóéï 3. Ëýêåéï 4. ÁíùôÝñá 5. ÁíùôÜôç

10. ÅðÜããåëìá ðáôÝñá ..................................................................................................................................................................................................................................................................................................

11. ÃñáììáôéêÝò ãíþóåéò ìçôÝñáò: 1. Äçìïôéêü 2. ÃõìíÜóéï 3. Ëýêåéï 4. ÁíùôÝñá 5. ÁíùôÜôç

12. ÅðÜããåëìá ìçôÝñáò ................................................................................................................................................................................................................................................................................................

13. Ôüðïò êáôáãùãÞò ðáôÝñá ......................................................................................................................................................................................................................................................................................

14. Ôüðïò êáôáãùãÞò ìçôÝñáò .....................................................................................................................................................................................................................................................................................

15. ÌÝíåôå óå: 1. Ìïíïêáôïéêßá 2. Ðïëõêáôïéêßá

16. Áí ìÝíåôå óå ðïëõêáôïéêßá, óå ðïéüí üñïöï; .....................................................................................................................................................................................................................................................

17. Ðüóá Üôïìá ìÝíåôå óõíïëéêÜ óôï óðßôé; ..............................................................................................................................................................................................................................................................

18. Ðüóá õðíïäùìÜôéá Ý÷åé ôï óðßôé óáò; ..................................................................................................................................................................................................................................................................

19. ÊïéìÜôáé ôï ðáéäß ìå Üëëïí óôï äùìÜôéï; Íáß ¼÷é

20. Áí íáé ìå ðïéüí; 1. Áäåëöü/Þ 2. Ãïíéü 3. Ðáððïý - ÃéáãéÜ

21. Ôé èÝñìáíóç Ý÷åé ôï óðßôé óáò; êáëïñéöÝñ îõëüóïìðá óüìðá ðåôñåëáßïõ air condition Üëëç (äéåõêñéíßóôå)

..........................................................................................................................................................................................................................................................................................................................................

22. Êáðíßæåôå; Áí íáé ðïéïò; ÐáôÝñáò ÌçôÝñá ¢ëëïò ¢ëëïòðüóá êáðíßæåé ôçí çìÝñá ....................... : ............................. : ........................... : ...........................ðüóá êáðíßæåé ìÝóá óôï óðßôé ....................... : ............................. : ........................... : ...........................ðüóá ÷ñüíéá êáðíßæåé ....................... : ............................. : ........................... : ...........................Áí ôï "Ýêïøå" ìÝ÷ñé ðüôå êÜðíéæå (Ýôïò) ....................... : ............................. : ........................... : ...........................

23. Êáðíßæåôå óôï áõôïêßíçôï; Íáé ¼÷é

24. Åßäïò êáðíéóôéêÞò óõíÞèåéáò: ðßðá ôóéãÜñï Üëëï

25. ÐïéÜ ìÜñêá ôóéãÜñùí êáðíßæåôå;............................................................................................................

26. ÄéáèÝôåé ôï óðßôé óáò êÞðï Þ áõëÞ; Íáé ¼÷é

27. ¼ôáí êÜðïéïò ôñßôïò öñïíôßæåé ôï ðáéäß óáò áõôüò: 1. åßíáé êáðíéóôÞò Íáß ¼÷é 2. êáðíßæåé üôáí åßíáé ìå ôï ðáéäß; Íáß ¼÷é 3. ðüóåò þñåò óõíïëéêÜ ôçí åâäïìÜäá âñßóêåôáé ìå ôï ðáéäß;.......................................................................................

28. Ðüóåò þñåò ôçí åâäïìÜäá ðáßæåé ôï ðáéäß óáò Ýîù áðü ôï óðßôé åêôüò áðü áõôÝò ðïõ ðáßæåé óôï ó÷ïëåßï;

................................................................................................................................................................................................................................................................................................................................

29. Áóêåßôáé óõóôçìáôéêÜ óå êÜðïéï Üèëçìá; Íáé ¼÷é

30. Áí íáé óå ðïéü; ....................................................................................................................................................................

31. Ðüóåò þñåò ôçí åâäïìÜäá; ................................................................................................................................................

ÌÅÑÏÓ É

1. Ðáñïõóßáóå ðïôÝ ôï ðáéäß óáò äýóðíïéá Þ óõñéãìü ("ãáôÜêéá"); ÍÁÉ Ï×É Áí áðáíôÞóåôå ü÷é óõíå÷ßóôå óôçí åñþôçóç 7

2. Ðáñïõóßáóå ðïôÝ ôï ðáéäß óáò äýóðíïéá Þ óõñéãìü ("ãáôÜêéá") ôïõò ôåëåõôáßïõò 12 ìÞíåò; ÍÁÉ Ï×É Áí áðáíôÞóåôå ü÷é óõíå÷ßóôå óôçí åñþôçóç 7

3. Ðüóåò öïñÝò ðáñïõóßáóå ôï ðáéäß óáò åðåéóüäéá ìå óõñéãìü ôïõò ôåëåõôáßïõò 12 ìÞíåò; Êáìßá 1-3 4-12 > 12


4. Ôïí ôåëåõôáßï ìÞíá ðüóåò öïñÝò ðáñïõóßáóå áíÜëïãá åðåéóüäéá; ÊáíÝíá ¸íá-äýï äýï-ôÝóóåñá > ôÝóóåñá

5. Ðüóåò öïñÝò êáôÜ ìÝóï üñï ôïõò ôåëåõôáßïõò 12 ìÞíåò îõðíïýóå ôï ðáéäß óáò ôï âñÜäõ ëüãù ôïõ óõñéãìïý;ðïôÝ ëéãüôåñï áðü ìéá íý÷ôá ôçí åâäïìÜäá ìßá Þ ðåñéóóüôåñåò íý÷ôåò ôçí åâäïìÜäá

6. Óôç äéÜñêåéá ôùí ôåëåõôáßùí 12 ìçíþí Þôáí ðïôÝ ï óõñéãìüò ôüóï óïâáñüò þóôå ç ïìéëßá ôïõ ðáéäéïý óáò áíÜìåóá óå äýï áíáðíïÝò íá ðåñéïñßæåôáé ìüíï óå ìéá Þ äýï ëÝîåéò;ÍÁÉ Ï×É

7. ¼ôáí ôñÝ÷åé áñêåôÜ Ý÷åé âÞ÷á Þ âñÜóéìï óôï óôÞèïò; ÍÁÉ Ï×É

8. Óôç äéÜñêåéá ôùí ôåëåõôáßùí 12 ìçíþí åß÷å ðïôÝ ôï ðáéäß óáò îçñüâç÷á ôï âñÜäõ; (ðÝñá áðü âÞ÷á ðïõ íá ïöåßëåôáé óå êñõïëüãçìá;) ÍÁÉ Ï×É

9. Ðáñïõóßáóå ðïôÝ ôï ðáéäß óáò åðåéóüäéá ðïõ äéáãíþóèçêáí ùò Üóèìá, áóèìáôïåéäÞò, áëëåñãéêÞ Þ óðáóôéêÞ âñïã÷ßôéäá êáôÜ ôïõò ôåëåõôáßïõò 12 ìÞíåò; ÍÁÉ Ï×É

10. Åß÷å ðïôÝ Üóèìá ôï ðáéäß óáò; ÍÁÉ Ï×É

11. Ðüóåò ìÝñåò ëåßðåé ôï ÷ñüíï áðü ôï óôáèìü ëüãù ðñïâëçìÜôùí ôïõ áíáðíåõóôéêïý; ................................................................................................................................................................................

12. Ðüóåò öïñÝò åðéóêÝðôåôáé ãéáôñü ôï ÷ñüíï ãéá ðñïâëÞìáôá áíáðíåõóôéêïý; ..............................................................................................................................................................................................

13. Ðüóåò öïñÝò Ý÷åé ìðåé óôï íïóïêïìåßï ãéá áíáðíåõóôéêÜ ðñïâëÞìáôá; .......................................................................................................................................................................................................

14. Ðüóåò íý÷ôåò ôï ÷ñüíï îõðíÜåé ìå âÞ÷á Þ äýóðíïéá; .......................................................................................................................................................................................................................................

15. ¸÷åé ôï ðáéäß ôéò ôåëåõôáßåò 2 åâäïìÜäåò ðåñÜóåé âñïã÷ßôéäá, ðíåõìïíßá Þ óïâáñü êñõïëüãçìá; ÍÁÉ Ï×É

16. Áí íáß, ôé öÜñìáêá ðÞñå; .......................................................................................................................................................................................................................................................................................

17. ¸÷åé ðÜèçóç ôïõ êáñäéáããåéáêïý óõóôÞìáôïò (êáñäéïðÜèåéá) ãéá ôçí ïðïßá ðáñáêïëïõèåßôáé áðü (ðáéäï)êáñäéïëüãï; ÍÁÉ Ï×É

18. ÕðÜñ÷åé ìÝëïò ôçò ïéêïãÝíåéáò ìå âñïã÷éêü Üóèìá; ÍÁÉ Ï×É

19. Áí íáß, ðïéü; ìçôÝñá ðáôÝñáò áäåëöüò ãéáãéÜ ðáððïýò óýíïëï áôüìùí

20. Ó÷åäéáóìüò ãåíåáëïãéêïý äÝíäñïõ.

ÌÅÑÏÓ ÉÉ

1. Ðáñïõóßáóå ðïôÝ ôï ðáéäß óáò ñéíéêÞ êáôáññïÞ, öôÜñíéóìá, ìðïýêùìá Þ öáãïýñá óôç ìýôç äéáñêåßáò ìåñéêþí åâäïìÜäùí Þ ðåñéóóüôåñï, ðïõ íá ìçí ïöåßëåôáé óå êñõïëüãçìá;ÍÁÉ Ï×É Áí áðáíôÞóåôå ü÷é óõíå÷ßóôå óôçí åñþôçóç 6

2. ÊáôÜ ôïõò ôåëåõôáßïõò 12 ìÞíåò ðáñïõóßáóå ðïôÝ ôï ðáéäß óáò ñéíéêÞ êåôáññïÞ, öôÜñíéóìá, ìðïýêùìá Þ öáãïýñá óôç ìýôç äéáñêåßáò ìåñéêþí åâäïìÜäùí Þ ðåñéóóüôåñï ðïõ íá ìçíïöåßëåôáé óå êñõïëüãçìá;ÍÁÉ Ï×É Áí áðáíôÞóåôå ü÷é óõíå÷ßóôå óôçí åñþôçóç 6

3. Ôïõò ôåëåõôáßïõò 12 ìÞíåò ôá ðáñáðÜíù óõíïäåýôçêáí áðü öáãïýñá êáé äÜêñõá óôá ìÜôéá;ÍÁÉ Ï×É

4. Óå ðïéüí áðü ôïõò ðñïçãïýìåíïõò 12 ìÞíåò åìöáíßóôçêå ôï ðñüâëçìá;ÉáíïõÜñéïò ÌÜñôéïò ÌÜéïò Éïýëéïò ÓåðôÝìâñéïò ÍïÝìâñéïò ÖåâñïõÜñéïò Áðñßëéïò Éïýíéïò Áýãïõóôïò Ïêôþâñéïò ÄåêÝìâñéïò

5. ÊáôÜ ôïõò ôåëåõôáßïõò 12 ìÞíåò, ðüóï áõôü ôï ðñüâëçìá åðçñÝáóå ôéò êáèçìåñéíÝò äñáóôçñéüôçôåò ôïõ ðáéäéïý;Êáèüëïõ Ëßãï ÁñêåôÜ Ðïëý

6. ÐÜó÷åé áðü "×ÑÏÍÉÁ" åðéðåöõêßôéäá (êïêêéíßëá Þ öáãïýñá Þ äÜêñõá óôá ìÜôéá): ÍÁÉ Ï×É

ÌÅÑÏÓ ÉÉÉ

1. Åß÷å ðïôÝ ôï ðáéäß óáò åîÜíèçìá óôï äÝñìá ìå öáãïýñá, (ôï ïðïßï ðüôå) åìöáíéæüôáí êáé ðüôå åîáöáíéæüôáí; Þ ðïõ íá åìöáíßæåôáé êáé íá åîáöáíßæåôáé ãéá ìåãÜëá ÷ñïíéêÜ äéáóôÞìáôá;ÍÁÉ Ï×É Áí áðáíôÞóåôå ü÷é óõíå÷ßóôå óôçí åñþôçóç 7

2. Åß÷å ðïôÝ åîÜíèçìá ìå öáãïýñá êáôÜ ôïõò ôåëåõôáßïõò 12 ìÞíåò;ÍÁÉ Ï×É Áí áðáíôÞóåôå ü÷é óõíå÷ßóôå óôçí åñþôçóç 7

3. Áõôü ôï åîÜíèçìá ðñïóÝâáëå êÜðïéá öïñÜ ìéá áðü ôéò áêüëïõèåò ðåñéï÷Ýò;Ôéò ðôõ÷Ýò ôïõ áãêþíá, ôçí ðåñéï÷Þ ðßóù áð' ôá ãüíáôá, ìðñïóôÜ áð' ôá ãüíáôá, ìðñïóôÜ áð' ôïõò áóôñáãÜëïõò, êÜôù áð' ôïõò ãëïõôïýò, ãýñù áð' ôï ëáéìü, ôá áõôéÜ Þ ôç ìýôç;ÍÁÉ Ï×É

4. Óå ôç çëéêßá ðñùôï-åìöáíßóôçêá áõôü ôï åîÜíèçìá; êÜôù ôùí 2 ÷ñïíþí ìåôáîý 2-4 ÷ñïíþí ðÜíù áðü 5 ÷ñïíþí

5. Õðï÷þñçóå ðïôÝ ôåëåßùò áõôü ôï åîÜíèçìá ôïõò ôåëåõôáßïõò 12 ìÞíåò;ÍÁÉ Ï×É

6. Ôïõò ôåëåõôáßïõò 12 ìÞíåò, ðüóï óõ÷íÜ, êáôÜ ìÝóï üñï, Ýìåéíå ôï ðáéäß óáò îýðíéï ôç íý÷ôá, ëüãù ôçò öáãïýñáò áð' ôï åîÜíèçìá;ðïôÝ óôïõò ôåëåõôáßïõò 12 ìÞíåò ëéãüôåñï áðü ìßá íý÷ôá ôçí åâäïìÜäá ìßá Þ ðåñéóóüôåñåò íý÷ôåò ôçí åâäïìÜäá

7. Åß÷å ðïôÝ Ýêæåìá ôï ðáéäß óáò; ÍÁÉ Ï×É


ÅÑÙÔÇÌÁÔÏËÏÃÉÏ ÐÏÕ ×ÑÇÓÉÌÏÐÏÉÇÈÇÊÅ ÓÔÇÍ ÅÐÁÍÁÎÉÏËÏÃÇÓÇ ÔÙÍ ÐÁÉÄÉÙÍ ÌÅ ÁÓÈÌÁ

Ðáñáêáëþ óõìðëçñþóôå:1. Ïíïìáôåðþíõìï ðáéäéïý ..........................................................................................................................................................................................................................................................................................2. Çëéêßá ðáéäéïý ...........................................................................................................................................................................................................................................................................................................3. ¼íïìá ðáôÝñá ...........................................................................................................................................................................................................................................................................................................4. Çëéêßá ðáôÝñá ............................................................................................................................................................................................................................................................................................................5. ¼íïìá ìçôÝñáò ..........................................................................................................................................................................................................................................................................................................6. Çëéêßá ìçôÝñáò ..........................................................................................................................................................................................................................................................................................................

1. Êáðíßæåôå; Áí íáé ðïéïò; ÐáôÝñáò ÌçôÝñá ¢ëëïò ¢ëëïòðüóá êáðíßæåé ôçí çìÝñá ........................... : ............................. : ........................... : ...........................ðüóá êáðíßæåé ìÝóá óôï óðßôé ........................... : ............................. : ........................... : ...........................ðüóá ÷ñüíéá êáðíßæåé ........................... : ............................. : ........................... : ...........................Áí ôï "Ýêïøå" ìÝ÷ñé ðüôå êÜðíéæå (Ýôïò) ........................... : ............................. : ........................... : ...........................ÐáñáôçñÞóåéò ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

2. Ðáñïõóßáóå ðïôÝ ôï ðáéäß óáò äýóðíïéá Þ óõñéãìü ("ãáôÜêéá") ôïõò ôåëåõôáßïõò 12 ìÞíåò; ÍÁÉ Ï×É

3. Ðüóåò öïñÝò ðáñïõóßáóå ôï ðáéäß óáò åðåéóüäéá óå óõñéãìü ôïõò ôåëåõôáßïõò 12 ìÞíåò; Êáìßá 1-3 4-12 > 12

4. Ôïí ôåëåõôáßï ìÞíá ðüóåò öïñÝò ðáñïõóßáóå áíÜëïãá åðåéóüäéá; ÊáíÝíá ¸íá-äýï äýï-ôÝóóåñá > ôÝóóåñá

5. Ðüóåò öïñÝò êáôÜ ìÝóï üñï ôïõò ôåëåõôáßïõò 12 ìÞíåò îõðíïýóå ôï ðáéäß óáò ôï âñÜäõ ëüãù ôïõ óõñéãìïý;ðïôÝ ëéãüôåñï áðü ìéá íý÷ôá ôçí åâäïìÜäá ìßá Þ ðåñéóóüôåñåò íý÷ôåò ôçí åâäïìÜäá

6. Óôç äéÜñêåéá ôùí ôåëåõôáßùí 12 ìçíþí Þôáí ðïôÝ ï óõñéãìüò ôüóï óïâáñüò þóôå ç ïìéëßá ôïõ ðáéäéïý óáò áíÜìåóá óå äýï áíáðíïÝò íá ðåñéïñßæåôáé ìüíï óå ìéá Þ äýï ëÝîåéò;ÍÁÉ Ï×É

7. Óôç äéÜñêåéá ôùí ôåëåõôáßùí 12 ìçíþí åß÷å ðïôÝ ôï ðáéäß óáò îçñüâç÷á ôï âñÜäõ; (ðÝñá áðü âÞ÷á ðïõ íá ïöåßëåôáé óå êñõïëüãçìá;)ÍÁÉ Ï×É

8. Ðüóåò ìÝñåò ëåßðåé ôïí ôåëåõôáßï ÷ñüíï áðü ôï óôáèìü ëüãù ðñïâëçìÜôùí ôïõ áíáðíåõóôéêïý; ..............................................................................................................................................................

9. Ðüóåò öïñÝò åðéóêÝðôåôáé ãéáôñü ôï ÷ñüíï ãéá ðñïâëÞìáôá áíáðíåõóôéêïý; ................................................................................................................................................................................................

10. Ðüóåò öïñÝò Ý÷åé ìðåé óôï íïóïêïìåßï ãéá áíáðíåõóôéêÜ ðñïâëÞìáôá; .......................................................................................................................................................................................................

11. Ðüóåò íý÷ôåò ôï ÷ñüíï îõðíÜåé ìå âÞ÷á Þ äýóðíïéá; .......................................................................................................................................................................................................................................

ÅÑÙÔÇÌÁÔÏËÏÃÉÏ ÐÏÕ ×ÑÇÓÉÌÏÐÏÉÇÈÇÊÅ ÃÉÁ ÔÇÍ ÁÑ×ÉÊÇ ÅÊÔÉÌÇÓÇ ÔÇÓ ÓÕ×ÍÏÔÇÔÁÓÔÏÕ ÂÑÏÃ×ÉÊÏÕ ÁÓÈÌÁÔÏÓ

ÇÌÅÑÏÌÇÍÉÁ: ..........................................................................................................................................................................................................................................................................................................ÏÍÏÌÁ-ÅÐÙÍÕÌÏ ÐÁÉÄÉÏÕ: ......................................................................................................... ....................................................................................................................................................................ÇÌÅÑÏÌÇÍÉÁ ÃÅÍÍÇÓÇÓ: ..................................................................................................................................................................................................................................................................................ÂÑÅÖÏÍÇÐÉÁÊÏÓ ÓÔÁÈÌÏÓ: .............................................................................................................................................................................................................................................................................ÄÉÅÕÈÕÍÓÇ ÊÁÔÏÉÊÉÁÓ: ......................................................................................................................................................................................................................................................................................ÔÇËÅÖÙÍÏ: ................................................................................................................................................................................................................................................................................................................ÂÁÑÏÓ ÓÙÌÁÔÏÓ: .....................................................................................................................................................................................................................................................................................................ÕØÏÓ ÓÙÌÁÔÏÓ: ......................................................................................................................................................................................................................................................................................................ÅÐÁÃÃÅËÌÁ ÐÁÔÅÑÁ: .............................................................................................................. ..............................................................................................................................................................................ÅÐÁÃÃÅËÌÁ ÌÇÔÅÑÁÓ: ............................................................................................................. ...........................................................................................................................................................................

1. ÐáñïõóéÜæåé ôï ðáéäß óáò êÜðïéï áðü ôá ðáñáêÜôù óõìðôþìáôá ôïí ôåëåõôáßï ÷ñüíï;(Óõìðëçñþóôå ìå × Ýíá Þ ðåñéóóüôåñá ôåôñÜãùíá áíôßóôïé÷á).

á) ÂÞ÷áâ) Êñßóåéò äýóðíïéáòã) ÐñùéíÞ áðü÷ñåìøçä) Äýóðíïéá óôçí Üóêçóçå) Óõñéãìüò ("ãáôÜêéá", "âñÜóéìï")

óô) Ôßðïôá áðü ôá ðáñáðÜíù

2. Ðáñïõóßáóå ôï ðáéäß óáò ìéá Þ ðåñéóóüôåñåò áðü ôéò ðáñáêÜôù íüóïõò áðü ôüôå ðïõ ãåííÞèçêå;á) ÁóèìáôéêÞ âñïã÷ßôéäáâ) ÓðáóôéêÞ âñïã÷ßôéäáã) ¢óèìáä) Ðíåõìïíßáå) Óõ÷íÜ êñõïëïãÞìáôá

óô) Âñïã÷üóðáóìï

3. ÐáñïõóéÜæåé ôï ðáéäß óáò:á) ÁëëåñãéêÞ ñéíßôéäá â) ÊÜðïéá Üëëç áëëåñãßá ã) Ôßðïôá áðü ôá ðáñáðÜíù

Áí ðáñïõóéÜæåé êÜðïéá Üëëç áëëåñãßá, ðáñáêáëïýìå íá äéåõêñéíßóåôå, ðïéá áêñéâþò åßíáé áõôÞ.

4. ÅÜí ôï ðáéäß óáò ðáñïõóßáóå êñßóç äýóðíïéáò, óå ðïéá çëéêßá óõíÝâç ãéá ðñþôç öïñÜ; ............................................................................................................................................................................

5. Áí ÷ñçóéìïðïéåß öÜñìáêá ãéá ôïõò ðíåýìïíåò, óå ðïéá ìïñöÞ åßíáé áõôÜ;á) ÅéóðíïÝò â) Äéóêßá (÷Üðéá) ã) Óéñüðéá

Ðáñáêáëïýìå, íá óçìåéþóåôå ôá ïíüìáôá ôùí öáñìÜêùí: ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

Åðéðïëáóìüò óõìðôùìÜôùí ÃáóôñïïéóïöáãéêÞòÐáëéíäñïìéêÞò Íüóïõ óå ¸ëëçíåò áóèåíåßòìå âñïã÷éêü Üóèìá

ÐÅÑÉËÇØÇ. Óå ðïëëÝò ìåëÝôåò, ðñïåñ÷üìåíåò êõñßùò áðü ôçíÅõñþðç êáé ôç Âüñåéá ÁìåñéêÞ, Ý÷åé äéáðéóôùèåß õøçëüò åðéðï-ëáóìüò óõìðôùìÜôùí ÃáóôñïïéóïöáãéêÞò ÐáëéíäñïìéêÞò Íüóïõ(ÃÏÐÍ) óå áóèåíåßò ìå âñïã÷éêü Üóèìá. Óêïðüò ôçò ðáñïýóáòìåëÝôçò åßíáé ï êáèïñéóìüò ôïõ åðéðïëáóìïý óõìðôùìÜôùíÃÏÐÍ óå ¸ëëçíåò áóèìáôéêïýò áóèåíåßò. Óôç ìåëÝôç óõìðå-ñéåëÞöèçóáí 92 áóèåíåßò ìå âñïã÷éêü Üóèìá (50 Üíôñåò êáé 42ãõíáßêåò, ìÝóç çëéêßá 42,9 ±14,2 Ýôç), ïé ïðïßïé ðáñáêïëïõèïý-íôáé óôá åîùôåñéêÜ éáôñåßá ôçò êëéíéêÞò ìáò êáèþò êáé 85 õãéåßòìÜñôõñåò áíôßóôïé÷çò çëéêßáò êáé öýëïõ. Áðü üëá ôá Üôïìá æç-ôÞèçêå ç óõìðëÞñùóç ðñïêáèïñéóìÝíïõ åñùôçìáôïëïãßïõ ôïïðïßï Ý÷åé ðñïôõðïðïéçèåß äéåèíþò ãéá ôïí êáèïñéóìü óõìðôù-ìÜôùí ÃÏÐÍ (ïðéóèïóôåñíéêü êáýóïò, üîéíåò áíáãùãÝò). Ï åðé-ðïëáóìüò ôïõ ïðéóèïóôåñíéêïý êáýóïõò êáé ôùí üîéíùí áíáãù-ãþí Þôáí õøçëüôåñïò óôá Üôïìá ìå Üóèìá (81,5% êáé 57,6% áíôß-óôïé÷á) óõãêñéôéêÜ ìå ôçí ïìÜäá åëÝã÷ïõ (32,9% êáé 17,6%,p<0.01). ÊáíÝíá áðü ôá öÜñìáêá êáôÜ ôïõ Üóèìáôïò äåí ó÷åôé-æüôáí ìå áõîçìÝíï åðéðïëáóìü óõìðôùìÜôùí ÃÏÐÍ. Áðü ôááðïôåëÝóìáôá ôçò ìåëÝôçò ìáò óõìðåñáßíåôáé üôé ïé ¸ëëçíåòáóèåíåßò ìå âñïã÷éêü Üóèìá ðïõ áðåõèýíïíôáé óå Ýíá êÝíôñï ôñé-ôïâÜèìéáò ðåñßèáëøçò Ý÷ïõí õøçëü åðéðïëáóìü óõìðôùìÜôùíÃÏÐÍ. Åðéðñüóèåôåò ìåëÝôåò óôï ãåíéêü ðëçèõóìü ôùí áóèìá-ôéêþí áóèåíþí èåùñïýíôáé áðáñáßôçôåò ãéá ôçí åîáãùãÞ áóöá-ëÝóôåñùí óõìðåñáóìÜôùí. Ðíåýìùí 2003, 16(1):59-66.

ÅÉÓÁÃÙÃÇ

Ðñþôïò ï Sir William Osler ôï 1892 óôï óýããñáììÜ ôïõ �The Princi-ples and Practice of Medicine�, õðïóôÞñéîå üôé Ýíá áðü ôá åêëõôéêÜ áßôéáôïõ Üóèìáôïò ìðïñåß íá åßíáé ç õðåñðëÞñùóç ôïõ óôïìÜ÷ïõ Þ ç ðñüóëç-

KëéíéêÞ ÌåëÝôç

Á. Ñïýóóïò,Åéñ. ÃåñïãéÜííç,Åéñ. ËáãïãéÜííç,Ö. Ôóéìðïýêáò,Í. Öéëßððïõ,Åéñ. Çëéüðïõëïò

9ç ÐíåõìïíïëïãéêÞ KëéíéêÞ N.N.È.A. �H ÓÙTHPIA�,AèÞíá

Áëëçëïãñáößá:Pïýóóïò AíáóôÜóéïòIåñïóïëýìùí 20-22, Ðë. AìåñéêÞò, AèÞíáTK 11252, Tçë.: 8646215

ËÝîåéò - êëåéäéÜ: Âñïã÷éêü Üóèìá, Ãáóôñïïéóï-öáãéêÞ ÐáëéíäñïìéêÞ Íüóïò, åðéðïëáóìüò, üîé-íåò áíáãùãÝò, ïðéóèïóôåñíéêü êáýóïò


âñïã÷éêü Üóèìá åßôå óôo ðëáßóéo ôáêôéêÞò ðáñáêïëïý-èçóçò ãíùóôïý âñïã÷éêïý Üóèìáôïò. Áðáñáßôçôá êñé-ôÞñéá ãéá íá óõìðåñéëçöèåß ôåëéêÜ Ýíáò áóèåíÞò óôçìåëÝôç Þôáí ôá åîÞò: á)áýîçóç ôçò FEV1 óå ðïóïóôü>15% ìåôÜ ÷ïñÞãçóç åéóðíåüìåíïõ âñïã÷ïäéáóôáëôé-êïý êáé â)éóôïñéêü êáé êëéíéêÞ åîÝôáóç óõìâáôÜ ìå ôçäéÜãíùóç âñïã÷éêïý Üóèìáôïò.

Ôçí ïìÜäá ôùí ìáñôýñùí áðïôÝëåóáí õãéåßò åíÞëé-êåò (áðüëõôá ðñïôõðïðïéçìÝíïé ùò ðñïò ôçí çëéêßá êáéôï öýëï ìå ôïõò áóèìáôéêïýò), ïé ïðïßïé ðñïóÞëèáí ôçíßäéá ÷ñïíéêÞ ðåñßïäï óôá åîùôåñéêÜ éáôñåßá ãéá ðñï-ãñáììáôéóìÝíï õãåéïíïìéêü Ýëåã÷ï. Óå üëá ôá Üôïìáðïõ ðåñéåëÞöèçóáí óôçí ìåëÝôç (áóèåíåßò êáé ìÜñôõ-ñåò) Ýãéíå åíçìÝñùóç ãéá ôï óêïðü ôçò åñãáóßáò êáé æç-ôÞèçêå ç Ýããñáöç óõãêáôÜèåóç ãéá ôç óõììÝôï÷Þ ôïõò.

Óå üëïõò ôïõò áóèåíåßò ìå âñïã÷éêü Üóèìá êáôá-ãñÜöçêå ôï ÷ñïíéêü äéÜóôçìá áðü ôç äéÜãíùóç ôçò íü-óïõ êáé ç ëáìâáíüìåíç êáôÜ ôçí ðåñßïäï ôçò ìåëÝôçòöáñìáêåõôéêÞ áãùãÞ (èåïöõëëéíïý÷á, â-äéåãÝñôåò,âñùìéïý÷ï éðñáôñüðéï, åéóðíåüìåíá Þ per os êïñôéêï-óôåñïåéäÞ). Åðßóçò, æçôÞèçêå áðü êÜèå áóèåíÞ íá ðå-ñéãñÜøåé, ÷ñçóéìïðïéþíôáò ìßá âáèìïëïãçìÝíç êëßìá-êá (áðü 0 Ýùò 4), ðéèáíÞ åðéäåßíùóç ôçò íüóïõ ìåôÜëÞøç á) êáöåßíçò, â) áëêïüë, ã) âáñÝïò ãåýìáôïò êáéä)ìåôÜ êáôÜêëéóç óå äéÜóôçìá ìéêñüôåñï ôùí äýï ùñþíáðü ôï ôåëåõôáßï ãåýìá. ÔÝëïò, óå üëïõò ôïõò áóèåíåßòÝãéíáí ôñåéò äéáäï÷éêÝò óðéñïìåôñÞóåéò (Ýëåã÷ïò FEV1,FVC, FEV1/FVC), áðü ôéò ïðïßåò êáé êáôáãñÜöçêå áõôÞìå ôéò õøçëüôåñåò ôéìÝò.

Óôç óõíÝ÷åéá æçôÞèçêå, ôüóïí áðü ôïõò áóèìáôéêïýòáóèåíåßò üóïí êáé áðü ôïõò ìÜñôõñåò, ç óõìðëÞñùóçåéäéêïý åñùôçìáôïëïãßïõ ãéá ôçí åêôßìçóç ôïõ åðéðï-ëáóìïý ôùí óõìðôùìÜôùí ÃÏÐÍ. Ôï åñùôçìáôïëüãéïáõôü áðïôåëåß áêñéâÞ ìåôÜöñáóç óôçí åëëçíéêÞ åñù-ôçìáôïëïãßïõ ôï ïðïßï ÷ñçóéìïðïéÞèçêå, ãéá ðñþôçöïñÜ, áðü ôïõò Field et al ôï 1996 êáé Ýêôïôå ÷ñçóéìï-ðïéåßôáé óå ðëÞèïò áíôßóôïé÷ùí ìåëåôþí ãéá ôçí åêôßìç-óç óõìðôùìÜôùí ÃÏÐÍ5 (ÐáñÜñôçìá).

ÔÝëïò, êáôáãñÜöçêå ç êáôáíÜëùóç áðü üëá ôá Üôï-ìá ôïõ äåßãìáôïò ôïõò ôåëåõôáßïõò 2 ìÞíåò ðñï ôçò ìå-ëÝôçò: á)áíôéüîéíùí, â) Ç2- áíáóôïëÝùí, ã) áíáóôïëÝùíáíôëßáò ðñùôïíßïõ êáé ä) ðñïêéíçôéêþí óêåõáóìÜôùí.

ÓôáôéóôéêÞ áíÜëõóç: Ôá ðåñéãñáöéêÜ ìåãÝèç ãéá ôéòðïóïôéêÝò ìåôáâëçôÝò áíáöÝñïíôáé ùò ìÝóç ôéìÞ ± 1óôáèåñÞ áðüêëéóç. Ïé óõó÷åôßóåéò ìåôáîý äõáäéêþí

øç óõãêåêñéìÝíùí ôñïöþí1. Ôüôå áêüìá äåí åß÷å ïñé-óôåß ùò ÃáóôñïïéóïöáãéêÞ Ðáëéíäñüìçóç (ÃÏÐ) çðáëéíäñüìçóç ãáóôñéêïý ðåñéå÷ïìÝíïõ áðü ôï óôüìá-÷ï óôïí ïéóïöÜãï. ¸ôóé, ç èåùñßá ãéá ôçí ðñüêëçóçáóèìáôéêþí êñßóåùí áðü ãáóôñéêÝò äéáôáñá÷Ýò ðáñÝ-ìåéíå ÷ùñßò äéåñåýíçóç ãéá Ýíá ðåñßðïõ áéþíá. ÓÞìå-ñá, áíáãíùñßæåôáé ùò éäéáßôåñç êëéíéêÞ ïíôüôçôá ç Ãá-óôñïïéóïöáãéêÞ ÐáëéíäñïìéêÞ Íüóïò (ÃÏÐÍ), ç ïðïßáïñßæåôáé ùò êÜèå êëéíéêïðáèïëïãïáíáôïìéêÞ êáôÜóôá-óç ïöåéëüìåíç óôç ÃÏÐ. Èåùñåßôáé åîáéñåôéêÜ óõ÷íÞðÜèçóç, åêäçëþíåôáé ìå ïðéóèïóôåñíéêü êáýóïò êáéüîéíåò áíáãùãÝò, åíþ ôåêìçñéùìÝíåò åðéðëïêÝò ôçòáðïôåëïýí ç ïéóïöáãßôéäá êáé ï ïéóïöÜãïò Barrett2.

Ôá ôåëåõôáßá Ýôç Ý÷åé äéåñåõíçèåß óå óçìáíôéêüâáèìü ç ðéèáíÞ óõó÷Ýôéóç ÃÏÐÍ - âñïã÷éêïý Üóèìá-ôïò. Óôç äéåèíÞ âéâëéïãñáößá óõíáíôÜôáé ðëÞèïò áíá-öïñþí óôïí áõîçìÝíï åðéðïëáóìü óõìðôùìÜôùí ÃÏÐÍ(ïðéóèïóôåñíéêü êáýóïò, üîéíåò áíáãùãÝò) óå áóèåíåßòìå âñïã÷éêü Üóèìá. Óôéò ðåñéóóüôåñåò üìùò ðåñéðôþ-óåéò, ðñüêåéôáé ãéá áíáäñïìéêÝò ìåëÝôåò óå áóèìáôé-êïýò áóèåíåßò ïé ïðïßïé õðïâÜëëïíôáé óå äéåñåýíçóçãéá óõìðôùìáôïëïãßá áðü ôï ãáóôñåíôåñéêü óýóôçìá.Ôá äåäïìÝíá óå ìç åðéëåãìÝíïõò ðëçèõóìïýò áóèìáôé-êþí åßíáé ðåíé÷ñÜ. Ïé ëßãåò õðÜñ÷ïõóåò ìåëÝôåò ðñïÝñ-÷ïíôáé áðü êÝíôñá ðáñáêïëïýèçóçò áóèåíþí ìå âñïã-÷éêü Üóèìá óå Åõñþðç êáé Âüñåéá ÁìåñéêÞ êáé áíáöÝ-ñïõí åðéðïëáóìü óõìðôùìÜôùí ÃÏÐÍ ï ïðïßïò êõìáß-íåôáé áðü 50% Ýùò 72%3-5. Óôçí, ðñïóéôÞ óå åìÜò, åëëç-íéêÞ âéâëéïãñáößá äåí õðÜñ÷åé áíôßóôïé÷ç áíáöïñÜ.

Óêïðüò ôçò ðáñïýóáò ìåëÝôçò åßíáé ï êáèïñéóìüòôïõ åðéðïëáóìïý óõìðôùìÜôùí ÃÏÐÍ óå ¸ëëçíåòáóèìáôéêïýò áóèåíåßò ïé ïðïßïé ðáñáêïëïõèïýíôáé óåêÝíôñï áíáðíåõóôéêþí ðáèÞóåùí ôñéôïâÜèìéáò ðåñß-èáëøçò. Åðéäéþêåôáé åðßóçò ç äéåñåýíçóç ðéèáíÞò óõ-ó÷Ýôéóçò ôùí óõìðôùìÜôùí áõôþí ìå ôç ÷ïñçãïýìåíçáíôéáóèìáôéêÞ öáñìáêåõôéêÞ áãùãÞ.

ÕËÉÊÏ-ÌÅÈÏÄÏÓ

Ç ðáñïýóá ìåëÝôç ðñáãìáôïðïéÞèçêå êáôÜ ôç äéÜñ-êåéá åíüò Ýôïõò êáé óõãêåêñéìÝíá áðü ôçí 1ç Éáíïõá-ñßïõ 2000 Ýùò êáé ôçí 31ç Äåêåìâñßïõ 2000. ÕðïøÞöéïéãéá ìåëÝôç èåùñÞèçêáí üëïé ïé áóèåíåßò ïé ïðïßïé, ôçóõãêåêñéìÝíç ÷ñïíéêÞ ðåñßïäï, ðñïóÞëèáí óôá åîùôå-ñéêÜ éáôñåßá ôçò êëéíéêÞò ìáò åßôå ìå íåïäéáãíùóèÝí


ëõóç ôùí äåäïìÝíùí ôïõ ðßíáêá Ýäåéîå üôé, ï åðéðïëá-óìüò, ôüóïí ôïõ ïðéóèïóôåñíéêïý Üëãïõò üóïí êáé ôùíüîéíùí áíáãùãþí, Þôáí õøçëüôåñïò, óå âáèìü óôáôé-óôéêÜ óçìáíôéêü, óôïõò áóèåíåßò ìå âñïã÷éêü Üóèìá.Åðßóçò, ç óõìðôùìáôïëïãßá ôïõ âñïã÷éêïý Üóèìáôïòêáé ç áíÜãêç ÷ñÞóçò åéóðíåüìåíùí âñïã÷ïäéáóôáëôé-êþí åìöáíßæïíôáí áõîçìÝíåò óå ìåãÜëï áñéèìü áóèìá-ôéêþí áóèåíþí (65,2% êáé 52,1% áíôßóôïé÷á) êáôÜ ôéòðåñéüäïõò óõìðôùìÜôùí ÃÏÐÍ. ÔÝëïò, äéáðéóôþèçêåüôé ïé áóèìáôéêïß áóèåíåßò åìöáíßæïõí óõ÷íüôåñá óõ-ìðôùìáôïëïãßá áðü ôï áíáðíåõóôéêü óýóôçìá ìåôÜ ôïöáãçôü (áóèìáôéêïß: 38%, ìÜñôõñåò: 5,8%, p<0,01) êáéôçí êáôÜêëéóç (áóèìáôéêïß: 23,1%, ìÜñôõñåò: 1,1%,p<0.01). Áíôßèåôá, ï åðéðïëáóìüò áíáðíåõóôéêþí óõ-ìðôùìÜôùí ìåôÜ ôçí êáôáíÜëùóç êáöÝ (áóèìáôéêïß:4,3%,ìÜñôõñåò: 2,3%, p=0,7) êáé áëêïüë (áóèìáôéêïß:10,8%, ìÜñôõñåò: 5,8%, p=0,2) äåí âñÝèçêå íá äéáöÝ-ñåé ìåôáîý ôùí äýï ïìÜäùí.

Ïé áóèìáôéêïß áóèåíåßò, óôç óõíôñéðôéêÞ ôïõò ðëåéï-øçößá, åëÜìâáíáí â-äéåãÝñôåò (85 áóèåíåßò, 92,3%) êáéåéóðíåüìåíá êïñôéêïóôåñïåéäÞ (80 áóèåíåßò, 87%). ÔáðïóïóôÜ êáôáíÜëùóçò èåïöõëëéíïý÷ùí (29 áóèåíåßò,31,5%) êáé per os êïñôéêïóôåñïåéäþí (21 áóèåíåßò,22,8%) Þôáí óçìáíôéêÜ ÷áìçëüôåñá. Ç óôáôéóôéêÞ áíÜ-ëõóç äåí Ýäåéîå íá ó÷åôßæåôáé ç ÷ñÞóç êÜðïéïõ áðü ôáðñïáíáöåñüìåíá óêåõÜóìáôá ìå áõîçìÝíç ðéèáíüôç-ôá åìöÜíéóçò ïðéóèïóôåñíéêïý êáýóïõò Þ/êáé üîéíùíáíáãùãþí (p<0.01 óå üëåò ôéò ðåñéðôþóåéò).

ÔÝëïò, óôïí ðßíáêá 3 áðåéêïíßæïíôáé ôá ðïóïóôÜ÷ñÞóçò áíôß-ÃÏÐÍ öáñìÜêùí áðü ôá Üôïìá ðïõ óõì-ìåôåß÷áí óôçí Ýñåõíá. Ç óõãêñéôéêÞ áíÜëõóç, ãéá êÜèåìßá áðü ôéò ôÝóóåñéò ìåãÜëåò êáôçãïñßåò (áíôéüîéíá, Ç2-áíáóôïëåßò, áíáóôïëåßò áíôëßáò ðñùôïíßïõ êáé ðñïêé-íçôéêÜ), Ýäåéîå õøçëüôåñá ðïóïóôÜ êáôáíÜëùóçò áðüôïõò áóèìáôéêïýò.

ÓÕÆÇÔÇÓÇ

Ôá áðïôåëÝóìáôá ôçò ìåëÝôçò ìáò äåß÷íïõí üôé ïé

Ðßíáêáò 2. Åðéðïëáóìüò óõìðôùìÜôùí ÃÏÐÍ óå áóèåíåßò êáé ìÜñôõñåò

Óõìðôþìáôá ÃÏÐÍ Áóèìáôéêïß Í (%) ÌÜñôõñåò Í (%) ÔéìÞ p

Ïðéóèïóôåñíéêü êáýóïò 75 (81,5) 28 (32,9) 0.009¼îéíåò áíáãùãÝò 53 (57,6) 15 (17,6) 0.006

ìåôáâëçôþí Ýãéíáí ìå ôçí åöáñìïãÞ ôïõ Fischer�s exacttest. Ï ðáñáìåôñéêüò óõíôåëåóôÞò óõó÷åôßóåùò êáôÜSpearman ÷ñçóéìïðïéÞèçêå ãéá ôç óýãêñéóç ìåôáîý äéá-ôÜîéìùí ìåôáâëçôþí. ÔÝëïò, ï åðéðïëáóìüò óõìðôùìÜ-ôùí ìåôáîý áóèìáôéêþí êáé ìáñôýñùí óõãêñßèçêå ìåôçí åöáñìïãÞ ôçò äïêéìáóßáò x2 ìå äéüñèùóç êáôÜ Yate.Ç åðåîåñãáóßá ôùí áðïôåëåóìÜôùí Ýãéíå ôç ÷ñÞóç ôïõóôáôéóôéêïý ðñïãñÜììáôïò SPSS (SPSS Inc, IL, USA).ÄéáöïñÝò ìå ôéìÞ p ìéêñüôåñç ôïõ 0,05 èåùñÞèçêáíóôáôéóôéêÜ óçìáíôéêÝò.

ÁÐÏÔÅËÅÓÌÁÔÁ

Óôç ìåëÝôç óõìðåñéåëÞöèçóáí óõíïëéêÜ 92 áóèåíåßòìå âñïã÷éêü Üóèìá (50 Üíôñåò êáé 42 ãõíáßêåò, ìÝóççëéêßá 42,9 ±14,2 Ýôç) êáèþò êáé 85 õãéåßò ìÜñôõñåòáíôßóôïé÷çò çëéêßáò êáé öýëïõ. Óôïí ðßíáêá 1 áðåéêï-íßæïíôáé áíáëõôéêÜ ôá äçìïãñáöéêÜ óôïé÷åßá ôïõ äåßã-ìáôïò êáèþò êáé ôá áðïôåëÝóìáôá ôïõ óðéñïìåôñéêïýåëÝã÷ïõ ôùí áóèìáôéêþí. ÊáôÜ ôçí áíÜëõóç ôùí áðï-ôåëåóìÜôùí ôçò óðéñïìÝôñçóçò, äåí ðñïÝêõøå óôáôéóôé-êÜ óçìáíôéêÞ äéáöïñÜ ôùí ôéìþí ôïõ äåßêôç FEV1/FVCáíÜìåóá óå áóèìáôéêïýò ìå óõìðôþìáôá ÃÏÐÍ (FEV1/FVC (%): 65,2±13,8) êáé óå áõôïýò ðïõ Þôáí åëåýèå-ñïé óõìðôùìÜôùí ÃÏÐÍ (FEV1/FVC (%): 69,1±12,8,p=0,1).

Ï ðßíáêáò 2 êáôáãñÜöåé ôïí åðéðïëáóìü óõìðôù-ìÜôùí ÃÏÐÍ óå áóèåíåßò êáé õãéåßò ìÜñôõñåò. Ç áíÜ-

Ðßíáêáò 1. ÄçìïãñáöéêÜ óôïé÷åßá äåßãìáôïò êáé óðéñïìåôñé-êÜ äåäïìÝíá áóèåíþí ìå âñïã÷éêü Üóèìá

Áóèìáôéêïß áóèåíåßò ÌÜñôõñåòN=92 N=85

Çëéêßá (Ýôç) 42,9 ±14,2 44,5±13,5¢íôñåò/Ãõíáßêåò 50/42 45/40FEV1 (%ðñïâëåðüìåíïõ) 86,5±12,3FVC (%ðñïâëåðüìåíïõ) 71,4±16,1FEV1/FVC (%) 67,2±14.1


Ðßíáêáò 3. ÊáôáíÜëùóç áíôéðáëéíäñïìéêþí óêåõáóìÜôùí áðü ôá Üôïìá ôçò ìåëÝôçò

Êáôçãïñßá Áóèìáôéêïß Í (%) ÌÜñôõñåò Í (%) ÔéìÞ p

Áíôéüîéíá 52 (56,5) 12 (14,1) 0,007Ç2-áíáóôïëåßò 48(52,1) 12 (14,1) 0,006Áíáóôïëåßò áíôëßáò 34 (36,9) 10 (11,7) 0,009ÐñïêéíçôéêÜ 35(38) 4 (4,7) 0,003

ôéóôéêÞ óçìáíôéêÞ äéáöïñÜ óõìðôùìÜôùí ÃÏÐÍ óåó÷Ýóç ìå õãéåßò ìÜñôõñåò9. Åßíáé âÝâáéï üìùò, üôé, ãéáôçí åîáãùãÞ áóöáëþí óõìðåñáóìÜôùí, áðáéôïýíôáé ðå-ñéóóüôåñåò ìåëÝôåò óôï ãåíéêü ðëçèõóìü ôùí áóèìáôé-êþí.

Ç åðéäåßíùóç ôùí áíáðíåõóôéêþí óõìðôùìÜôùí óåáóèìáôéêïýò êáôÜ ôéò ðåñéüäïõò óõìðôùìÜôùí ÃÏÐÍüðùò êáé ìåôÜ ôï öáãçôü êáé ôçí êáôÜêëéóç (ðáñáôç-ñÞóåéò ïé ïðïßåò Ý÷ïõí áíáöåñèåß óôï ðáñåëèüí êáéåðéâåâáéþíïíôáé êáé óôçí ðáñïýóá ìåëÝôç) áðïôåëåßÝììåóç Ýíäåéîç áéôéïëïãéêÞò óõó÷Ýôéóçò ÃÏÐÍ-Üóèìá-ôïò. Åßíáé ãíùóôü üôé, óå áóèåíåßò ìå ÃÏÐÍ, ðáñáôç-ñïýíôáé ðáëéíäñïìÞóåéò ïîÝïò êáé ãáóôñéêïý ðåñéå÷ï-ìÝíïõ áðü ôï óôüìá÷ï óôïí êáôþôåñï ïéóïöÜãï, ç óõ-÷íüôçôá ôùí ïðïßùí åìöáíßæåôáé áõîçìÝíç êáôÜ ôç ìå-ôáãåõìáôéêÞ ðåñßïäï êáé ôçí êáôÜêëéóç2. ÓÞìåñá, èåù-ñåßôáé âÝâáéï üôé ç ðáëéíäñüìçóç ãáóôñéêïý ïîÝïò óôïíïéóïöÜãï ìðïñåß íá ðñïêáëÝóåé áíáðíåõóôéêÝò äéáôá-ñá÷Ýò ðïõ ðñïóïìïéÜæïõí ìå áõôÝò ôïõ âñïã÷éêïýÜóèìáôïò. ̧ ÷ïõí ðñïôáèåß ôÝóóåñéò äéáöïñåôéêïß ìç-÷áíéóìïß ãéá ôçí åñìçíåßá ôùí âëáðôéêþí åðéäñÜóåùíôçò ÃÏÐ óôï áíáðíåõóôéêü óýóôçìá:á) Áíôáíáêëáóôéêüò âñïã÷ïóðáóìüò (ïéóïöáãïâñïã÷é-

êü áíôáíáêëáóôéêü). Ç ðáëéíäñüìçóç ãáóôñéêïýðåñéå÷ïìÝíïõ èåùñåßôáé üôé äéåãåßñåé õðïäï÷åßò ôïõðíåõìïíïãáóôñéêïý óôïí ïéóïöáãéêü âëåííïãüíïêáé ðõñïäïôåß Ýíá áíôáíáêëáóôéêü ôüîï, ðñïêáëþ-íôáò âñïã÷ïóðáóìü. Óå ðëÞèïò ìåëåôþí, ôüóïí óåðåéñáìáôüæùá üóïí êáé óå áóèìáôéêïýò áóèåíåßòìå Þ ÷ùñßò ÃÏÐÍ, Ý÷åé ôåêìçñéùèåß ç ìåßùóç ôçòåêðíåõóôéêÞò ñïÞò êáé ç áýîçóç ôçò áíôßóôáóçò ôùíáåñáãùãþí ìåôÜ áðü ôçí åíäïïéóïöáãéêÞ Ýã÷õóçïîÝïò. Ôá áðïôåëÝóìáôá áõôÜ äåí åðáíáëáìâÜíï-íôáé ìåôÜ ôç öáñìáêåõôéêÞ Þ ÷åéñïõñãéêÞ áíáóôïëÞôçò äñÜóçò ôïõ ðíåõìïíïãáóôñéêïý10-18.

â) ÁõîçìÝíç âñïã÷éêÞ áíôéäñáóôéêüôçôá. Óýìöùíá ìåôç èåùñßá áõôÞ, ç Ýêèåóç ôïõ ïéóïöáãéêïý âëåííï-

áóèåíåßò ìå âñïã÷éêü Üóèìá ðáñïõóéÜæïõí õøçëü åðé-ðïëáóìü ïðéóèïóôåñíéêïý êáýóïõò(81%) êáé üîéíùíáíáãùãþí (57%), óõìðôùìÜôùí äçëáäÞ ôá ïðïßá áðï-ôåëïýí ôéò êýñéåò êëéíéêÝò åêäçëþóåéò ôçò ÃÏÐÍ. Çáðïõóßá óõó÷Ýôéóçò ôùí óõìðôùìÜôùí áõôþí ìå êÜðïéïáðü ôá ÷ïñçãïýìåíá ãéá ôçí áíôéìåôþðéóç ôïõ Üóèìá-ôïò öÜñìáêá, åíéó÷ýåé ôçí ðéèáíüôçôá áõîçìÝíïõ åðé-ðïëáóìïý ôçò ÃÏÐÍ óôïõò áóèìáôéêïýò áóèåíåßò.

Ç äéåèíÞò âéâëéïãñáößá åßíáé ðëïýóéá óå áíáöï-ñÝò óôïí áõîçìÝíï åðéðïëáóìü óõìðôùìÜôùí ÃÏÐÍóå áóèåíåßò ìå âñïã÷éêü Üóèìá. ¼ìùò, ç ðñïóåêôéêÞáíáóêüðçóç äåß÷íåé üôé ïé ðåñéóóüôåñåò ìåëÝôåò ðñïÝñ-÷ïíôáé áðü ãáóôñåíôåñïëïãéêÝò êëéíéêÝò6-8. ¸ôóé, ôááðïôåëÝóìáôÜ ôïõò äåí åßíáé óõãêñßóéìá ìå áõôÜ ôçòðáñïýóáò ìåëÝôçò, áöïý áöïñïýí óå åðéëåãìÝíïõò ðëç-èõóìïýò áóèìáôéêþí ïé ïðïßïé Þäç õðïâÜëëïíôáé óåäéåñåýíçóç ãéá íïóÞìáôá ôïõ ðåðôéêïý. Óôéò ôñåéò ðÜ-íôùò ìåãÜëåò óåéñÝò áóèåíþí ðïõ ðñïÝñ÷ïíôáé áðüêÝíôñá áíáðíåõóôéêþí ðáèÞóåùí áíáöÝñåôáé åðéðïëá-óìüò óõìðôùìÜôùí ÃÏÐÍ. ðáñüìïéïò Þ êáé õøçëüôå-ñïò áõôïý ôçò ìåëÝôçò ìáò. ÓõãêåêñéìÝíá, óýìöùíá ìåôïõò Perrin-Foyalle et al, ôï 65% ôùí áóèìáôéêþí áóèå-íþí åìöáíßæåé óõìðôùìáôïëïãßá ÃÏÐÍ3. Ïé O�Connelet al áíáöÝñïõí ïðéóèïóôåñíéêü Üëãïò óôï 72% ôùíáóèåíþí êáé íõ÷ôåñéíÝò üîéíåò áíáãùãÝò óôï 50%4.ÔÝëïò, õøçëü åðéðïëáóìü óõìðôùìÜôùí ÃÏÐÍ óåáóèìáôéêïýò äéáðéóôþíïõí êáé ïé Field et al (70% ïðé-óèïóôåñíéêü Üëãïò, 55% üîéíåò áíáãùãÝò)5.

Åêåßíï ôï ïðïßï ðñÝðåé íá ôïíéóèåß åßíáé üôé, ôüóïíç ðáñïýóá ìåëÝôç üóïí êáé ïé ôñåéò ðñïáíáöåñüìåíåò,äåí åßíáé áðüëõôá áíôéðñïóùðåõôéêÝò ôïõ óõíüëïõ ôùíáóèåíþí ìå âñïã÷éêü Üóèìá, áöïý ðñïÝñ÷ïíôáé áðüêÝíôñá áíáöïñÜò êáé áöïñïýí óå áóèìáôéêïýò ìå óï-âáñÞ íüóï (ïé ïðïßïé óõíÞèùò åßíáé áõôïß ðïõ ÷ñÞæïõíôñéôïâÜèìéáò ðåñßèáëøçò). Óôç ìïíáäéêÞ Ýñåõíá óå ìçåðéëåãìÝíï ðëçèõóìü áóèìáôéêþí áóèåíþí, ç ïðïßáðñáãìáôïðïéÞèçêå ðñüóöáôá, äåí äéáðéóôþèçêå óôá-


íÝò íá åðéâåâáéþóïõí Þ íá áðïêëåßóïõí ôçí ðáñïõóßáÃÏÐ ùò åêëõôéêïý áéôßïõ áóèìáôéêÞò êñßóçò.

Óôçí áîéïëüãçóç ìåëåôþí ïé ïðïßåò åîåôÜæïõí ôçóõó÷Ýôéóç ÃÏÐÍ-Üóèìáôïò, Ýíá åðéðñüóèåôï ðñüâëç-ìá èåùñåßôáé ç äõó÷Ýñåéá åêôÝëåóçò, óå ìåãÜëï áñéè-ìü áóèåíþí, ôçò ïéóïöáãéêÞò ðå÷áìåôñßáò (pH-ìåôñßáò)ç ïðïßá êáé èåùñåßôáé ùò ç �gold-standard� åñãáóôç-ñéáêÞ ìÝèïäïò åêëïãÞò ãéá ôç äéÜãíùóç ôçò ÃÏÐÍ24.Ôï ãåãïíüò áõôü ðñÝðåé íá ëçöèåß õð� üøéí êáé êáôÜôçí áîéïëüãçóç ôùí áðïôåëåóìÜôùí ôçò ðáñïýóáò åñ-ãáóßáò ç ïðïßá êáé åßíáé ìßá ìåëÝôç ôïõ åðéðïëáóìïýôùí óõìðôùìÜôùí ôçò ÃÏÐÍ óå áóèìáôéêïýò áóèåíåßò,êáé óå êáìßá ðåñßðôùóç, ôçò ßäéáò ôçò íüóïõ. ÉäéáßôåñïåíäéáöÝñïí ðáñïõóéÜæïõí ðñüóöáôåò Ýñåõíåò óôéòïðïßåò åöáñìüóèçêå ç ìÝôñçóç ðßåóçò ôïõ êáôþôåñïõïéóïöáãéêïý óöéãêôÞñá êáé ç ïéóïöáãéêÞ pH-ìåôñßáóå áóèìáôéêïýò áóèåíåßò. Ôá áðïôåëÝóìáôá Ýäåéîáí:á) ÁõîçìÝíï åðéðïëáóìü ðáëéíäñïìéêþí åðåéóïäßùíáêüìá êáé óå áóèìáôéêïýò áóèåíåßò ÷ùñßò óõìðôþìá-ôá ÃÏÐÍ25,26 êáé â) ÷ñïíéêÞ óõó÷Ýôéóç ìåôáîý ôùí åðåé-óïäßùí áõôþí êáé ôùí áóèìáôéêþí êñßóåùí27.

Áðü ôá áðïôåëÝóìáôá ôçò ìåëÝôçò ìáò óõìðåñáßíå-ôáé üôé ïé ̧ ëëçíåò áóèåíåßò ìå âñïã÷éêü Üóèìá ðïõ ðá-ñáêïëïõèïýíôáé óå Ýíá êÝíôñï ôñéôïâÜèìéáò ðåñßèáë-øçò Ý÷ïõí õøçëü åðéðïëáóìü óõìðôùìÜôùí ÃÏÐÍ.Åðéðñüóèåôåò ìåëÝôåò áðáéôïýíôáé: á) ãéá ôçí åðéâå-âáßùóç ôùí áðïôåëåóìÜôùí ìáò óôï ãåíéêü ðëçèõóìüôùí áóèìáôéêþí áóèåíþí êáé â) ôïí Ýëåã÷ï ôçò èåùñç-ôéêÞò õðüèåóçò ôçò áéôéïëïãéêÞò óõó÷Ýôéóçò ÃÏÐÍ-Üóèìáôïò ç ïðïßá èá åñìÞíåõå éêáíïðïéçôéêÜ ôéò ðá-ñáôçñÞóåéò ìáò.

ãüíïõ óôï ãáóôñéêü ïîý Ý÷åé ùò áðïôÝëåóìá ôçí áý-îçóç ôçò áíôéäñáóôéêüôçôáò ôïõ ôñá÷åéïâñïã÷éêïýäÝíôñïõ óå Üëëá åîùãåíÞ åñåèßóìáôá19-21. ÐñÜãìá-ôé, Ý÷åé ôåêìçñéùèåß áõîçìÝíç áíôéäñáóôéêüôçôá ôùíâñüã÷ùí óå ìåôá÷ïëßíç Þ óå éóïêáðíéêü õðåñáåñé-óìü îçñïý áÝñá ìåôÜ áðü åíäïïéóïöáãéêÞ Ýã÷õóçïîÝïò22. Êáé óôçí ðåñßðôùóç áõôÞ åíï÷ïðïéåßôáé çåõåñåèéóôüôçôá ôïõ ðíåõìïíïãáóôñéêïý íåýñïõ,áöïý ôá áðïôåëÝóìáôá äåí åðáíáëáìâÜíïíôáé åÜí,ôçò Ýã÷õóçò ïîÝïò, ðñïçãçèåß ç ÷ïñÞãçóç áôñïðß-íçò.

ã) ÌéêñïåéóñïöÞóåéò. Ç åéóñüöçóç ïîÝïò åßíáé ÝíáòÜëëïò ìç÷áíéóìüò ï ïðïßïò Ý÷åé åíï÷ïðïéçèåß ãéáôçí ðñüêëçóç áóèìáôéêþí êñßóåùí óå áóèåíåßò ìåÃÏÐÍ. Óå ðåéñáìáôüæùá, Ý÷åé áðïäåé÷èåß üôé ç åðá-öÞ, áêüìá êáé åëá÷ßóôùí ðïóïôÞôùí, ïîÝïò ìå ôçíôñá÷åßá ðñïêáëåß Ýíôïíï âñïã÷üóðáóìï21. Åðßóçòóå ðåéñáìáôéêÜ ìïíôÝëá, äéáðéóôþèçêå üôé ç Ýã÷õ-óç óôï öÜñõããá ïîÝïò êáé ðåøßíçò ðñïäéáèÝôåé óååðáíåéëçììÝíá åðåéóüäéá ìéêñïåéóñïöÞóåùí15. ÓåìåëÝôåò óå áóèìáôéêïýò áóèåíåßò ìå ÃÏÐÍ åðéâå-âáéþèçêå ç Ýíôïíç âñïã÷éêÞ áíôßäñáóç ìåôÜ áðüêÜèå åðåéóüäéï ìéêñïåéóñüöçóçò23.Êáé ïé ôñåéò ðñïçãïýìåíåò èåùñßåò ðáñÝ÷ïõí, ìü-

íåò ôïõò Þ óå óõíäõáóìü, ôï èåùñçôéêü õðüâáèñï ôïïðïßï èá ìðïñïýóå íá åñìçíåýóåé ôïí áõîçìÝíï åðé-ðïëáóìü óõìðôùìÜôùí ÃÏÐÍ óå áóèìáôéêïýò áóèå-íåßò. Áí êáé ç õðüèåóç ôçò áéôéïëïãéêÞò óõó÷ÝôéóçòÃÏÐÍ-Üóèìáôïò ìðïñåß íá èåùñçèåß éäéáßôåñá åëêõ-óôéêÞ, ïé äõóêïëßåò óôçí áðüäåéîÞ ôçò åßíáé ìåãÜëåò,áöïý óÞìåñá äåí õðÜñ÷ïõí äéáãíùóôéêÝò ìÝèïäïé éêá-

SUMMARY

Prevalence of gastroesophageal reflux disease symptoms in bronchial asthma patients in Greece

A. Roussos, I. Gerogianni, I. Lagogianni, F. Tsimpoukas, N. Filippou, I. Eliopoulos

9th Department of Pulmonary Medicine, �SOTIRIA� Chest Diseases Hospital, Athens, Greece

A high prevalence of gastroesophageal reflux disease (GERD) symptoms in patients with bronchialasthma has been shown in several reports from North America and Europe. However, no data fromGreece are available. The aim of this study is to assess the prevalence of GERD symptoms in Greekasthmatics. A total of 92 asthmatics (50 males and 42 females, aged 42.9±14.2 years) referred to ouroutpatient clinic, and 85 age- and sex-matched healthy control subjects were asked to complete astructured questionnaire on the presence of GERD symptoms. The prevalence of heartburn andregurgitation was higher in asthmatics (81.5% and 57.6%, respectively) than in controls (32.9% and


17.6%, respectively, p<0.01). None of the medications routinely used in the treatment of asthma wasassociated with increased prevalence of GERD symptoms. Our results suggest that Greek asthmaticsreferred to a tertiary care center have a significantly higher prevalence of GERD symptoms comparedto controls. Additional studies in the general population of asthmatic patients are required to furtherclarify the relationship between asthma and GERD in Greece. Pneumon 2003, 16(1):59-66.

Key words: Bronchial asthma, gastroesophageal reflux disease, prevalenc acid regurgitation, hearburn


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ÅÑÙÔÇÌÁÔÏËÏÃÉÏ ÂÑÏÃ×ÉÊÏÕ ÁÓÈÌÁÔÏÓ-ÃÁÓÔÑÏÏÉÓÏÖÁÃÉÊÇÓ ÐÁËÉÍ-ÄÑÏÌÉÊÇÓ ÍÏÓÏÕ

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ÅÑÙÔÇÓÇ 1ÐáñïõóéÜóáôå ðïôÝ ïðéóèïóôåñíéêü êáýóï (äçëáäÞ áßóèçìá êáøßìáôïò óôï óôÞèïò, ðßóù áðü ôï óôÝñíï, ìåôÜ áðüôï ãåýìá ç êáôÜ ôçí êáôÜêëéóç)?Íáé ¼÷é

Áí ç áðÜíôçóç óôçí åñþôçóç 1 åßíáé ü÷é ìçí áðáíôÞóåôå óôçí åñþôçóç 2

ÅÑÙÔÇÓÇ 2Ôá óõìðôþìáôá ïðéóèïóôåñíéêïý êáýóïõ Þôáí óõ÷íüôåñá:ÌåôÜ áðü ôï ãåýìá ÊáôÜ ôçí êáôÜêëéóç

ÅÑÙÔÇÓÇ 3ÊáôÜ ôéò ðåñéüäïõò ôïõ ïðéóèïóôåñíéêïý êáýóïõò áíáöÝñáôå áí êÜðïéï áðü ôá óõìðôþìáôá ôïõ âñïã÷éêïý Üóèìá-ôïò åìöáíßæåôáé áõîçìÝíï:ÂÞ÷áò: ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá Äýóðíïéá: ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá Óõñéãìüò: ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá


ÅÑÙÔÇÓÇ 4ÊáôÜ ôéò ðåñéüäïõò ôïõ ïðéóèïóôåñíéêïý êáýóïõ áíáöÝñáôå áí ç áíÜãêç ãéá ÷ñÞóç öáñìÜêùí ãéá ôï Üóèìá åìöá-íßæåôáé áõîçìÝíç?ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá

ÅÑÙÔÇÓÇ 5ÐáñïõóéÜóáôå ðïôÝ üîéíåò áíáãùãÝò (äçëáäÞ åðéóôñïöÞ ôçò ôñïöÞò ç áßóèçìá ïîÝïò óôï óôüìá)?Íáé ¼÷é

Áí ç áðÜíôçóç óôçí åñþôçóç 5 åßíáé ü÷é ìçí áðáíôÞóåôå óôéò åñùôÞóåéò 6-8

ÅÑÙÔÇÓÇ 6Ôá åðåéóüäéá üîéíùí áíÜãùãùí Þôáí óõ÷íüôåñáÌåôÜ áðü ôï ãåýìá ÊáôÜ ôçí êáôÜêëéóç

ÅÑÙÔÇÓÇ 7ÊáôÜ ôéò ðåñéüäïõò ôùí üîéíùí áíáãùãþí áíáöÝñáôå áí êÜðïéï áðü ôá óõìðôþìáôá ôïõ âñïã÷éêïý Üóèìáôïòåìöáíßæåôáé áõîçìÝíï:ÂÞ÷áò: ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá Äýóðíïéá: ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá Óõñéãìüò: ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá ×ñÞóç öáñìÜêùí ãéá ôï Üóèìá: ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá

ÅÑÙÔÇÓÇ 8ÊáôÜ ôéò ðåñéüäïõò ôùí üîéíùí áíáãùãþí áíáöÝñáôå áí ç áíÜãêç ÷ñÞóçò öáñìÜêùí ãéá ôï Üóèìá åìöáíßæåôáéáõîçìÝíç?ÐïôÝ ÐåñéóôáóéáêÜ Óõ÷íÜ ÐÜíôá

Óçìåßùóç: Óå üëåò ôéò óåéñÝò åñùôçìÜôùí ùò èåôéêÞ èåùñÞèçêå ç áðÜíôçóç üôáí óõíïäåõüôáí áðü ôïõò ÷ñïíéêïýòðñïóäéïñéóìïýò: [3] óõ÷íÜ êáé [4] ðÜíôá. ÁðáíôÞóåéò ïé ïðïßåò óõíïäåõüôáí áðü ôïõò ÷ñïíéêïýò ðñïóäéïñéóìïýò[1] ðïôÝ êáé [2] ðåñéóôáóéáêÜ, èåùñÞèçêáí áñíçôéêÝò.

EíäéáöÝñïõóá Ðåñßðôùóç

Eðéêïéíùíþí õäñïêÝöáëïò êáé âáñéÜ õðïíáôñéáéìßáóå áóèåíÞ ìå öõìáôéþäç ìçíéããßôéäá

Áëëçëïãñáößá:Ö. Êëïýâá-ÌïëõâäÜÈçóÝùò 3ÊçöéóéÜÁÈÇÍÁ 14564Ôçë. 210 5534109e-mail: [email protected]

×. ÓéíÜíç1,Ö. ÔóéäåìéÜäïõ1,Ì. Ìé÷áëéÜ1,Ê. ÑïõêÜò1,Á. Êïõôóßêïõ1,Ã. ÐáíôáæÞò2,Ö. Êëïýâá-ÌïëõâäÜ1

ÐÅÑÉËÇØÇ. ÐáñïõóéÜæåôáé ç ðåñßðôùóç áóèåíïýò 19 åôþí áðüôï ÐáêéóôÜí ìå öõìáôéþäç ìçíéããßôéäá, óå Ýäáöïò êåã÷ñïåéäïýòöõìáôßùóçò, ðïõ åéóÞ÷èç óôç ÌÅÈ óå êþìá êáé ìå âáñéÜ õðïíá-ôñéáéìßá. Óå Üìåóç äéåñåýíçóç ìå áîïíéêÞ ôïìïãñáößá åãêåöÜ-ëïõ äéáðéóôþèçêå ðáñïõóßá ïîÝïò åðéêïéíùíïýíôïò õäñïêåöÜ-ëïõ êáé ï áóèåíÞò õðïâëÞèçêå óå åðÝìâáóç ãéá ôïðïèÝôçóç åîù-ôåñéêÞò ðáñï÷Ýôåõóçò ÅÍÕ. Ï õäñïêÝöáëïò åßíáé óõ÷íÞ åðéðëï-êÞ ôçò öõìáôéþäïõò ìçíéããßôéäáò êáé ìðïñåß íá ïäçãÞóåé óå èÜ-íáôï. Ç ôïðïèÝôçóç åîùôåñéêÞò ðáñï÷Ýôåõóçò Ý÷åé èåñáðåõôé-êÞ êáé ðñïãíùóôéêÞ áîßá ãéá ôï áí èá ùöåëçèåß ï áóèåíÞò áðü ôçìüíéìç âáëâßäá. Ç ôïðïèÝôçóç ìüíéìçò êïéëéïðåñéôïíáúêÞò ðá-ñï÷Ýôåõóçò âåëôéþíåé ôçí ðñüãíùóç, éäéáßôåñá óôïõò áóèåíåßòðïõ ðáñïõóéÜæïíôáé ìå åëÜ÷éóôá íåõñïëïãéêÜ åëëåßììáôá. Ç íåõ-ñïëïãéêÞ åðéäåßíùóç óå áóèåíÞ ðïõ èåñáðåýåôáé ãéá öõìáôéþäçìçíéããßôéäá ìðïñåß íá Ý÷åé ðïëëÝò áéôßåò êáé óôo ðëáßóéo ôçò äéå-ñåýíçóçò ÷ñåéÜæåôáé ðÜíôá åðåßãïõóá áêôéíïëïãéêÞ åêôßìçóç ìåáîïíéêÞ ôïìïãñáößá åãêåöÜëïõ. Ðíåýìùí 2003, 16(1):74-79.

ÅÉÓÁÃÙÃÇ

Ç åðßðôùóç ôçò öõìáôßùóçò ðïéêßëåé áðü 9 ðåñéðôþóåéò áíÜ 100.000ðëçèõóìü áíÜ Ýôïò óôéò ÇÐÁ Ýùò 110-165 ðåñéðôþóåéò áíÜ 100.000 ðëç-èõóìü áíÜ Ýôïò óôéò áíáðôõóóüìåíåò ÷þñåò ôçò Áóßáò êáé ôçò ÁöñéêÞò1.

Óôç ÅëëÜäá ôá óôïé÷åßá ìÝ÷ñé ôï 1993 äåß÷íïõí äéáñêÞ ðôùôéêÞ ðï-ñåßá ôçò åðßðôùóçò. Ôï 1992 åß÷áìå 20 ðåñéðôþóåéò áíÜ 100.000 ðëçèõ-óìü áíÜ Ýôïò2. Ç ôÜóç áõôÞ áíáìÝíåôáé íá ôñïðïðïéçèåß ìå ôçí åßóïäïðëçèõóìþí áðü ÷þñåò üðïõ ç íüóïò åíäçìåß. Ç öõìáôßùóç èá óõíáíôÜ-ôáé üëï êáé óõ÷íüôåñá óôçí ÷þñá ìáò, ãé� áõôü êáé ÷ñåéÜæåôáé õøçëüòäåßêôçò õðïøßáò ãéá ôçí Ýãêáéñç äéÜãíùóç ôçò íüóïõ. ÐáñïõóéÜæåôáé çðåñßðôùóç áóèåíïýò ìå êñõøéãåíÞ ìïñöÞ êåã÷ñïåéäïýò öõìáôßùóçò, çäéÜãíùóç ôçò ïðïßáò äéÝëáèå êáé åîåëß÷èçêå óå öõìáôéþäç ìçíéããßôéäá.

1ÌïíÜäá ÅíôáôéêÞò Èåñáðåßáò Ð.Ã.Í. �ÈñéÜóéï�,2Íåõñï÷åéñïõñãéêÞ ÊëéíéêÞ Ð.Ã.Í. �ÈñéÜóéï�

ËÝîåéò - êëåéäéÜ: Öõìáôéþäçò ìçíéããßôéò, êåã-÷ñïåéäÞò öõìáôßùóç, åðéêïéíùíþí õäñïêÝöá-ëïò, õðïíáôñéáéìßá


ÅÑÃÁÓÔÇÑÉÁÊÏÓ ÅËÅÃ×ÏÓ: Áðü ôïí áäñü åñ-ãáóôçñéáêü Ýëåã÷ï ôá ðáèïëïãéêÜ åõñÞìáôá Þôáí :Ht:33,7%, Hb:11,1mg/dl, (MCV:80,5fl, MCH:26,6pg,MCHC:33g/dl) ËåõêÜ : 5800/mm³ (Ð: 93%, Ë: 3%, ÌÌ:3%), AMÐ: 127.000/mm³, ÔÊÅ: 80 mm ôçí 1ç þñá, ÷ñü-íïò ðñïèñïìâßíçò: 17,6" (1,53 INR), ëåõêþìáôá:5,6 g/dl, ëåõêùìáôßíåò: 2,96 g/dl, óöáéñßíåò: 2,69 g/dl, LDH:557 u/l, CPK: 578 u/l, Na: 118 mEq/l, Cl: 89 mEq/l, Ca:1,83 mmol/l. Õðïëïãéæüìåíç ùóìùôéêüôçôá ïñïý: 249,6mosm/kg. AntiHCV(+) ìå Elisa. ÅÂ ïýñùí: 1025, Naïýñùí: 96 mEq/l, Ê ïýñùí: 51,3 mEq/l. Ôá áÝñéá áßìá-ôïò óôïí áíáðíåõóôÞñá ìå FiO2 0.35 Þôáí: PO2 96mmHg, PCO2 32,4mmHg, ph 7,48, BE 2,2. Aðü ôçí á/áèþñáêïò åðéâåâáéþèçêå ç êåã÷ñïåéäÞò åéêüíá (Åéêü-íá 1).

Áðü ôïí õðüëïéðï åñãáóôçñéáêü Ýëåã÷ï: ÅîÝôáóçÅÍÕ: Ü÷ñïõí, äéáõãÝò, êýôôáñá 10/mm³, ëåýêùìá <20mg%, ãëõêüæç 47 mg/dl, ìå áíôßóôïé÷ç ôéìÞ ãëõêüæçòïñïý 125mg/dl, LDH 15 U/l. Gram ÷ñþóç: áñíçôéêÞ.ÊáëëéÝñãåéá (Ê/á) ãéá êïéíÜ ìéêñüâéá: óôåßñá. ×ñþóçZiehl Nielsen: áñíçôéêÞ. Ç áíß÷íåõóç ôïõ DNA ôïõ ìõ-êïâáêôçñéäßïõ ìå ôç ìÝèïäï ôçò áëõóéäùôÞò áíôßäñá-óçò ðïëõìåñÜóçò (PCR), Þôáí èåôéêÞ. Ê/á ãéá ìõêïâá-êôçñßäéá ìå ôç ìÝèïäï Bactec: èåôéêÞ.

Äåßãìáôá ôñá÷åéïâñïã÷éêþí åêêñßóåùí: ×ñþóç

ÐÁÑÏÕÓÉÁÓÇ ÐÅÑÉÐÔÙÓÇÓ

ÉÓÔÏÑÉÊÏ: ¢íäñáò 19 åôþí áðü ôï ÐáêéóôÜí, äéá-êïìßóôçêå óôç ÌÅÈ áðü ÐáèïëïãéêÞ ÊëéíéêÞ ôùí Áèç-íþí äéáóùëçíùìÝíïò, óå ìç÷áíéêü áåñéóìü, ëüãù êù-ìáôþäïõò êáôÜóôáóçò áðü 24þñïõ.

Ï áóèåíÞò, ðáéäß ðïëõìåëïýò ïéêïãÝíåéáò, åß÷å Ýñ-èåé óôçí ÅëëÜäá ðñéí 4 ìÞíåò. ¹ôáí Üíåñãïò êáé óéôé-æüôáí ðëçììåëþò. Ðáñïõóßáæå ðõñåôü áðü 3,5 ìÞíåò,ãéá ôïí ïðïßï íïóçëåýôçêå ðñéí 3 ìÞíåò ãéá 10 ìÝñåò óåÜëëï íïóïêïìåßï êáé åîÞëèå ÷ùñßò éäéáßôåñåò ïäçãßåò.Ï ðõñåôüò Þôáí áðïãåõìáôéíüò ìÝ÷ñé 38,5°C ìå óõíï-äü áíïñåîßá êáé êáôáâïëÞ. ÌåôÜ ôçí Ýîïäü ôïõ, åðß ÝíáìÞíá áíáöÝñåôáé üôé äåí ðáñïõóßáæå ðõñåôü, ðáñÜ ôçíåðéìïíÞ ôçò áíïñåîßáò êáé êáêïõ÷ßáò. Óôç óõíÝ÷åéáåìöÜíéóå êáé ðÜëé ðõñåôü, ãéá ôïí ïðïßï ÷ïñçãÞèçêåáðü éäéþôç ãéáôñü ôñéìåèïðñßìç-óïõëöïìåèïîáæüëç.Ìéá åâäïìÜäá ðñéí ôçí åéóáãùãÞ ôïõ áíáöÝñïíôáé ðôþ-óç áíôéêåéìÝíùí áðü ôá ÷Ýñéá, áäõíáìßá âÜäéóçò êáéáðü äéçìÝñïõ õðíçëßá êáé ëÞèáñãïò, ðñïïäåõôéêÜ åðé-äåéíïýìåíá. Ôçí ðáñáìïíÞ ôçò åéóáãùãÞò ôïõ óôç ÌÅÈðñïóÞëèå óôçí ÐáèïëïãéêÞ ÊëéíéêÞ óå êùìáôþäç êá-ôÜóôáóç. Ç á/á èþñáêá ðïõ Ýãéíå åêåß Ýäåéîå: äéÜóðáñ-ôåò ìéêñoïæþäåéò óêéÜóåéò (êåã÷ñïåéäÞ åéêüíá). ̧ ãéíåïóöõïíùôéáßá ðáñáêÝíôçóç êáé ç åîÝôáóç ôïõ åãêåöá-ëïíùôéáßïõ õãñïý (ÅÍÕ) Ýäåéîå: êýôôáñá 20/mm³, óÜê-÷áñï 30 mg/dl, ëåýêùìá 165 mg/dl. Áðü ôïí õðüëïéðïåñãáóôçñéáêü Ýëåã÷ï óçìåéþíåôáé ôéìÞ Na ïñïý 116mEq/l. Ìå ôçí õðïøßá öõìáôéþäïõò ìçíéããßôéäáò åôÝèçóå áãùãÞ ìå éóïíéáæßäç, ñéöáìðéêßíç, ðõñáæéíáìßäç,óôñåðôïìõêßíç êáé ðñåäíéæïëüíç. Äéáóùëçíþèçêå ëüãùôïõ åðéäåéíùìÝíïõ åðéðÝäïõ óõíåßäçóçò êáé äéáêïìß-óôçêå óôç ÌÅÈ ìåôÜ áðü 24ùñç íïóçëåßá. Ôï áôïìéêüáíáìíçóôéêü ôïõ áóèåíïýò Þôáí åëåýèåñï.

ÁÍÔÉÊÅÉÌÅÍÉÊÇ ÅÎÅÔÁÓÇ: Óôçí áíôéêåéìåíé-êÞ åîÝôáóç ðáñïõóßáæå ìåãÜëç áðßó÷íáíóç. Ç èåñìï-êñáóßá áðü ôï ïñèü Þôáí 38°C, ïé óöýîåéò 115/min, ïéáíáðíïÝò 18/min, ç áñôçñéáêÞ ðßåóç 130/90 mmHg. ÄåíõðÞñ÷áí éäéáßôåñá áêñïáóôéêÜ åõñÞìáôá áðü ôï èþ-ñáêá. Äåí õðÞñ÷å äéüãêùóç ôïõ Þðáôïò, óðëçíüò Þ ëåì-öáäÝíùí. Ïé êüñåò Þôáí éóïìåãÝèåéò ìå êáëü öùôïêé-íçôéêü áíôáíáêëáóôéêü, êëßìáêá ãëáóêþâçò 8. ÅìöÜ-íéæå áõ÷åíéêÞ äõóêáìøßá, êáé èåôéêü óçìåßï KerningÔá ôåíüíôéá áíôáíáêëáóôéêÜ Þôáí ìåéùìÝíá êáé ôá ðåë-ìáôéáßá óå êÜìøç. Ç Ìantoux Þôáí èåôéêÞ [12cm (PPD10)] .

Åéêüíá 1. Á/á èþñáêïò åéóáãùãÞò ìå åìöáíÞ ôçí ðáñïõóßáêåã÷ñïåéäïýò åéêüíáò.


Ziehl Nielsen: áñíçôéêÞ. Ç áëõóéäùôÞ áíôßäñáóç ðïëõ-ìåñÜóçò (PCR) Þôáí èåôéêÞ óå äýï áðü ôá ôñßá äåßãìá-ôá ðïõ åóôÜëçóáí. ÊáëëéÝñãåéá ãéá ìõêïâáêôçñßäéá ìåôç ìÝèïäï Lowenstein: áñíçôéêÞ. ÐïóïôéêÞ êáëëéÝñãåéáãéá êïéíÜ ìéêñüâéá áñíçôéêÞ.

Äåßãìá áßìáôïò êáé ïýñùí ðïõ óôÜëèçêå ãéá áíß-÷íåõóç DNA ìõêïâáêôçñéäßïõ öõìáôßùóçò ìå ôç ìÝ-èïäï áëõóéäùôÞò áíôßäñáóçò ðïëõìåñÜóçò (PCR) Þôáíáñíçôéêü.

Ç CT åãêåöÜëïõ ìå Ýã÷õóç óêéáãñáöéêïý ÝäåéîåðáèïëïãéêÞ ìçíéããéêÞ ðñüóëçøç ôçò óêéáãñáöéêÞò ïõ-óßáò óôéò âáóéêÝò äåîáìåíÝò, êáèþò êáé õäñïêÝöáëï ìåÞðéï ðåñéêïéëéáêü ïßäçìá, åíþ äåí õðÞñ÷áí ðáñåã÷õ-ìáôéêÝò áëëïéþóåéò (Åéêüíá 2).

ÐÏÑÅIÁ ÊÁÔA ÔÇ ÍÏÓÇËÅIÁ ÓÔÇ ÌÅÈ: ÏáóèåíÞò ôÝèçêå óå áãùãÞ ìå ôåôñáðëü ó÷Þìá áíôéöõ-ìáôéêÞò áãùãÞò: éóïíéáæßäç 300 mg, ñéöáìðéêßíç 600 mg,ðõñáæéíáìßäç 25 mg/kg ÓÂ, åèáìâïõôüëç 20 mg/kg ÓÂ,êáé ðñåäíéæïëüíç 1 mg/kg ÓÂ. ÕðåâëÞèç Üìåóá ôï ðñþ-ôï 24ùñï íïóçëåßáò ôïõ óå ÷åéñïõñãåßï ãéá ôçí ôïðïèÝ-ôçóç åîùôåñéêÞò ðáñï÷Ýôåõóçò ôïõ ÅÍÕ (Åéêüíá 3).

Ç âáñéÜ õðïíáôñéáéìßá, ðïõ ðáñïõóßáæå êáôÜ ôçíåéóáãùãÞ ôïõ, áíôéìåôùðßóôçêå ìå ÷ïñÞãçóç õðÝñôïíïõïñïý NaCl 2,7%, ìÝ÷ñé ôéìÞò Ía: 125 mÅq/l, êáé óôçóõíÝ÷åéá ìå ÷ïñÞãçóç öõóéïëïãéêïý ïñïý êáé öïõñï-óåìßäçò.

ÌåôÜ ôçí ôïðïèÝôçóç ôçò ðáñï÷Ýôåõóçò ôï åðßðåäï

Åéêüíá 2. ÁîïíéêÞ ôïìïãñáößá åãêåöÜëïõ ðñéí ôçí ôïðïèÝ-ôçóç åîùôåñéêÞò ðáñï÷Ýôåõóçò.

Åéêüíá 3. ÁîïíéêÞ ôïìïãñáößá åãêåöÜëïõ ìåôÜ ôçí ôïðïèÝ-ôçóç åîùôåñéêÞò ðáñï÷Ýôåõóçò.

óõíåßäçóÞò ôïõ âåëôéþèçêå êáé êáôÝóôç äõíáôÞ ç áðï-óùëÞíùóç ôïõ ôçí 5ç çìÝñá íïóçëåßáò. Ç íåõñïëïãéêÞåéêüíá üìùò Üëëáîå êáé ðáñïõóßáóå ìõúêÞ áäõíáìßáêáé óôá äõï êÜôù Üêñá, ìå õðåñï÷Þ äåîéÜ. Ç åðáíÜëç-øç ôçò CT åãêåöÜëïõ ëüãù áëëáãÞò ôçò íåõñïëïãéêÞòåéêüíáò Ýäåéîå ðáñïõóßá åìöñÜêôïõ óôï åðßðåäï ôùíáñéóôåñþí ðëÜãéùí âáóéêþí ãáããëßùí.

Ôçí 11ç ìÝñá áðü ôçí Ýíáñîç ôçò áíôéöõìáôéêÞò áãù-ãÞò ç ãåíéêÞ åîÝôáóç ôïõ ÅÍÕ åß÷å åðéóôñÝøåé óôï öõ-óéïëïãéêü. Ï áóèåíÞò õðoâëÞèçêå óå ôïðïèÝôçóç ìü-íéìçò êïéëéïðåñéôïíáúêÞò âáëâßäáò ðáñï÷Ýôåõóçò ôçí19ç ìÝñá íïóçëåßáò ôïõ êáé åîÞëèå áðü ôç ÌÅÈ.

ÓÕÆÇÔÇÓÇ

Õðïëïãßæåôáé üôé 10% üëùí ôùí áóèåíþí ìå öõìá-ôßùóç Ý÷ïõí óõììåôï÷Þ ôïõ ÊÍÓ3. Ç íüóïò ðáñéóôÜ åßôåáíáæùðýñùóç ðñïçãïýìåíçò ìüëõíóçò, åßôå íÝá ìüëõí-óç. Óôïé÷åßá áðü åðéäçìéïëïãéêÝò ìåëÝôåò ìå ôç ÷ñÞóçìïñéáêþí ôå÷íéêþí óôéò ÇÐÁ äåß÷íïõí üôé ðåñßðïõ óôï40% ôùí ðåñéðôþóåùí ðñüêåéôáé ãéá íÝá ëïßìùîç4 .

Ðñïãíùóôéêïß ðáñÜãïíôåò5 ãéá ôçí Ýêâáóç èåùñïý-íôáé: ç çëéêßá, ç õðïèñåøßá, ç ýðáñîç õðïêåßìåíçò ÷ñü-íéáò íüóïõ, ç ýðáñîç êåã÷ñïåéäïýò íüóïõ, ç ðáñïõóßáåóôéáêÞò óçìåéïëïãßáò, ç ðáñïõóßá õäñïêåöÜëïõ, ôïóôÜäéï ôçò íüóïõ, ôá ÷áìçëÜ åðßðåäá ãëõêüæçò êáé ôáðïëý áõîçìÝíá åðßðåäá ðñùôåßíçò óôï ÅÍÕ.

ÊëéíéêÜ ç öõìáôéþäçò ìçíéããßôéäá êáôáôÜóóåôáé óå


óôÜäéï ÉÉÉ Ý÷ïõí âáñéÜ ðñüãíùóç êáé èíçôüôçôá 51,9%.ÓõíéóôÜôáé ç Üìåóç ôïðïèÝôçóç ìüíéìçò êïéëéïðåñéôï-íáúêÞò ðáñï÷Ýôåõóçò óôïõò áóèåíåßò ìå êëéíéêü óôÜäéïÉÉ. Óôïýò áóèåíåßò ìå óôÜäéï ÉÉÉ ìðïñåß íá åðé÷åéñçèåßðñþôá ç ôïðïèÝôçóç åîùôåñéêÞò ðáñï÷Ýôåõóçò ÅÍÕ êáéíá åêôéìçèåß ç âåëôßùóç ôïõ åðéðÝäïõ óõíåßäçóçò. Çôõ÷üí áñ÷éêÞ èåôéêÞ áíôáðüêñéóç ôùí áóèåíþí áõôþíäåí åßíáé ðÜíôùò áðüëõôá ðñïãíùóôéêÞ ôçò ôåëéêÞò ôïõòÝêâáóçò9, ãéáôß ç óõíýðáñîç êáé Üëëùí âëáâþí åðéâá-ñýíåé ôçí ðñüãíùóç.

Ç õðïíáôñéáéìßá åßíáé óõ÷íü óõíïäü åýñçìá ôçòöõìáôéþäïõò ìçíéããßôéäáò êáé ôçò êåã÷ñïåéäïýò öõìá-ôßùóçò. Ï ìç÷áíéóìüò ìå ôïí ïðïßï óõìâáßíåé äåí åßíáéáðüëõôá äéåõêñéíéóìÝíïò. ̧ ÷åé áðïäïèåß óå óýíäñïìïáðñüóöïñçò Ýêêñéóçò áíôéäéïõñçôéêÞò ïñìüíçò (SIAD-H)10. Ï ìç÷áíéóìüò áõôüò üìùò äåí åîçãåß üëåò ôéò ðå-ñéðôþóåéò, áöïý ç AVP åßíáé ìç áíé÷íåýóéìç óå 10%ôùí áóèåíþí. ÐáñÜëëçëá Ý÷åé åíï÷ïðïéçèåß êáé ç õðå-ñÝêêñéóç íáôñéïõñçôéêïý ðåðôéäßïõ êáñäéáêÞò êáé åãêå-öáëéêÞò ðñïÝëåõóçò, ðïõ Ý÷åé ðåñéãñáöåß óáí óýíäñï-ìï áðþëåéáò Üëáôïò êåíôñéêÞò áéôéïëïãßáò (cerebral saltwasting syndrome)11. Óôçí ðåñßðôùóç ôïõ SIADH, çõðïíáôñéáéìßá ïöåßëåôáé óå áñáßùóç ìå öõóéïëïãéêü ÞåëÜ÷éóôá áõîçìÝíï åíäáããåéáêü üãêï, åíþ óôçí ðåñß-ðôùóç ôïõ óõíäñüìïõ áðþëåéáò Üëáôïò õðÜñ÷åé óõóôï-ëÞ ôïõ åíäáããåéáêïý üãêïõ, ëüãù áðñüóöïñçò íáôñéïý-ñçóçò áðü ôçí õðåñÝêêñéóç íáôñéïõñçôéêïý ðåðôéäßïõ.ÁíåîÜñôçôá áðü ôïí õðïêåßìåíï ìç÷áíéóìü, ç õðïíá-ôñéáéìßá âåëôéþíåôáé ìåôÜ ôçí Ýíáñîç ôçò áíôéöõìáôé-êÞò áãùãÞò. Ï áóèåíÞò ìáò ðáñïõóßáæå õðïíáôñéáéìßáôÝôïéáò âáñýôçôáò, ðïõ áðáéôïýóå ôç ÷ïñÞãçóç õðÝñ-ôïíïõ äéáëýìáôïò ãéá ôç äéüñèùóÞ ôçò. Óôç óõíÝ÷åéááíôéìåôùðßóôçêå ìå ÷ïñÞãçóç öõóéïëïãéêïý ïñïý êáéöïõñïóåìßäçò.

Ç áðüöáóç ãéá èåñáðåßá äåí ìðïñåß íá âáóéóôåßóôéò êáëëéÝñãåéåò, ëüãù ôçò êáèõóôÝñçóçò ôùí áðïôå-ëåóìÜôùí ôïõò. Ç ÷ñþóç ãéá ïîåÜíôï÷á âáêôÞñéá (Zi-ehl Nielsen) åßíáé èåôéêÞ ìüíï óå 10 - 20%. H äáãíùóôé-êÞ ôçò áðüäïóç ìðïñåß íá áõîçèåß åîåôÜæïíôáò ìåãá-ëýôåñç ðïóüôçôá ÅÍÕ (10 ml) êáèþò êáé ìå åðáíÜëç-øç ôçò ìåèüäïõ óå äéáäï÷éêÜ äåßãìáôá. Ç áíß÷íåõóçôïõ DNA ôïõ ìõêïâáêôçñéäßïõ ìå ôç ìÝèïäï ôçò áëõóé-äùôÞò áíôßäñáóçò ðïëõìåñÜóçò PCR Ý÷åé åõáéóèçóßáðïõ êõìáßíåôáé áðü 33-90% êáé åéäéêüôçôá 88-100%,óýìöùíá ìå ôéò äéÜöïñåò ìåëÝôåò12. Ç PCR ìðïñåß íá

ôñßá óôÜäéá.� ÓôÜäéï É: Ðñüäñïìç öÜóç ÷ùñßò íåõñïëïãéêÜ óõ-

ìðôþìáôá.� ÓôÜäéï ÉÉ: Óçìåßá åñåèéóìïý ôùí ìçíßããùí, ìå åëá-

öñÜ Þ ÷ùñßò äéáôáñá÷Þ ôïõ åðéðÝäïõ óõíåßäçóçò êáéåëÜóóïíá åóôéáêÜ íåõñïëïãéêÜ óçìåßá (ðáñÝóåéòêñáíéáêþí íåýñùí).

� ÓôÜäéï ÉÉÉ: ÓïâáñÞ äéáôáñá÷Þ ôïõ åðéðÝäïõ óõíåß-äçóçò, óðáóìïß, åóôéáêÜ íåõñïëïãéêÜ åëëåßììáôá.Ôï óôÜäéï ôçò íüóïõ èåùñåßôáé ï ðéï óçìáíôéêüò

ðñïãíùóôéêüò ðáñÜãùí. Ç èíçôüôçôá áíÝñ÷åôáé óå 50-70% ãéá ôïõò áóèåíåßò ìå íüóï óôáäßïõ ÉÉÉ. Ï áóèåíÞòðïõ ðåñéãñÜöåôáé ðáñïõóéÜóôçêå óå óôÜäéï ÉÉÉ.

ÔÝóóåñéò ïíôüôçôåò óõíèÝôïõí ôçí ðáèïëïãßá ôçòíüóïõ áðü ôï ÊÍÓ: á) ïé óõìöýóåéò, â) ç áðïöñáêôéêÞáããåéßôéäá áðü ôçí ïðïßá ðñïóâÜëëïíôáé éäßùò ç åããýòìÝóç åãêåöáëéêÞ êáé ïé äéáôéôñáßíïõóåò áñôçñßåò ôùíâáóéêþí ãáããëßùí ìå áðïôÝëåóìá ôç äçìéïõñãßá åìöñÜ-êôïõ, ã) ôá öõìáôþìáôá ðïõ åìöáíßæïíôáé óõ÷íüôåñáóôïõò ìåôùðéáßïõò êáé âñåãìáôéêïýò ëïâïýò êáé åßíáéìïíÞñç Þ ðïëëáðëÜ ìéêñÜ, üôáí ç öõìáôéþäçò ìçíéããß-ôéäá åßíáé åêäÞëùóç êåã÷ñïåéäïýò öõìáôßùóçò êáé ôÝ-ëïò ä) ç åãêåöáëßôéäá Þ ìõåëßôéäá.

Ï õäñïêÝöáëïò åßíáé óõ÷íÞ åðéðëïêÞ ôçò öõìáôéþ-äïõò ìçíéããßôéäáò6. Ç áíáöåñüìåíç óõ÷íüôçôÜ ôïõ åß-íáé 87% óôá ðáéäéÜ êáé 12% óôïýò åíÞëéêåò. Ï âáèìüòôïõ Ý÷åé ó÷Ýóç ìå ôç äéÜñêåéá ôùí óõìðôùìÜôùí. Ìðï-ñåß íá åßíáé: åðéêïéíùíïýíôïò ôýðïõ, ïöåéëüìåíïò óåðáñåìðüäéóç ôçò êõêëïöïñßáò ôïõ ÅÍÕ áðü åîßäñùìáóôéò âáóéêÝò äåîáìåíÝò êáé áíÜðôõîç óõìöýóåùí ôçòáñá÷íïåéäïýò ìÞíéããáò, Þ áðïöñáêôéêïý ôýðïõ, ïöåé-ëüìåíïò óå áðüöñáîç ôçò ñïÞò ôïõ ÅÍÕ áðü åíäïêïé-ëéáêü öõìÜôùìá Þ öõìÜôùìá óôïí õäñáãùãü ôïõ Sylv-ius. Ç ðáñï÷Ýôåõóç ôïõ ÅÍÕ ïäçãåß óå âåëôßùóç ôïõåðéðÝäïõ óõíåßäçóçò, ü÷é üìùò óå üëïõò ôïõò áóèåíåßò,ãéáôß ç áéôéïëïãßá åßíáé ðïëõðáñáãïíôéêÞ êáé õðÜñ÷ïõíêáé Üëëïé ðáñÜãïíôåò ðïõ ðñÝðåé íá ëçöèïýí õðüøéí,üðùò ç ðáñïõóßá éó÷áéìßáò, õðïíáôñéáéìßáò Þ åãêåöá-ëïðÜèåéáò (ïßäçìá ôïõ åãêåöáëéêïý ðáñåã÷ýìáôïòìÝóù áíïóïëïãéêïý ìç÷áíéóìïý)7. Ãéá êÜèå ìåìïíùìÝ-íç ðåñßðôùóç Ýíáò Þ êáé ðïëëáðëïß ìç÷áíéóìïß ìðïñåßíá åíÝ÷ïíôáé óôçí åðéäåßíùóç ôçò íåõñïëïãéêÞò êáôÜ-óôáóçò. Ïé áóèåíåßò ðïõ ðáñïõóéÜæïíôáé ìå êëéíéêüóôÜäéï ÉÉ ùöåëïýíôáé áðü ôçí ôïðïèÝôçóç êïéëéïðåñé-ôïíáúêÞò ðáñï÷Ýôåõóçò8, åíþ ïé áóèåíåßò ìå êëéíéêü


óå áóèåíÞ ðïõ ðÜó÷åé áðü TBC ìçíéããßôéäá ìðïñåß íáïöåßëåôáé óå ðïëëïýò ðáñÜãïíôåò, üðùò áíÜðôõîç õäñï-êåöÜëïõ, éó÷áéìßá, âáñéÜ õðïíáôñéáéìßá Þ åãêåöáëï-ðÜèåéá êáé ðñÝðåé íá åëÝã÷åôáé ðÜíôïôå êáé ìå áðåéêï-íéóôéêÝò ìåèüäïõò. ÐñÝðåé íá õðÜñ÷åé áõîçìÝíïò äåß-êôçò õðïøßáò áðü ôïí ðíåýìïíá ãéá ôçí ýðáñîç TBCëïßìùîçò, åéäéêÜ ãéá ôéò ÷ñüíéåò �êñõøéãåíåßò� ìïñöÝòôçò êåã÷ñïåéäïýò öõìáôßùóçò ðïõ ðáñïõóéÜæïíôáé ìåìüíá óçìåßá äéáëåßðïíôá ðõñåôü êáé áðþëåéá âÜñïõòêáé ÷ùñßò ôç ÷áñáêôçñéóôéêÞ áêôéíïëïãéêÞ åéêüíá.

Åõ÷áñéóôïýìå ôçí Êá Ëïõêßá ÆÝñâá, Åðßêïõñç Êá-èçãÞôñéá, ÅñãáóôÞñéï Ìéêñïâéïëïãßáò ÐáíåðéóôçìßïõÁèçíþí, ãéá ôçí åêôÝëåóç ôùí ìïñéáêþí ôå÷íéêþí.

áíé÷íåýåé ôï ìõêïâáêôçñßäéï ìÝ÷ñé 6 åâäïìÜäåò ìåôÜôçí Ýíáñîç ôçò èåñáðåßáò.

Ç èåñáðåßá ôçò öõìáôéþäïõò ìçíéããßôéäáò13 ðåñé-ëáìâÜíåé ñéöáìðéêßíç, éóïíéáæßäç, ðõñáæéíáìßäç, ìåðñïóèÞêç åíüò ôÝôáñôïõ ðáñÜãïíôá ãéá ôïõò ðñþôïõò2 ìÞíåò (åèáìâïõôüëç Þ óôñåðôïìõêßíç). Ç äéÜñêåéá ôçòèåñáðåßáò åßíáé 12 ìÞíåò åðåêôåéíüìåíç :óå 18 ìÞíåòüôáí ðáñáëåßðåôáé ç ðõñáæéíáìßäç. Ïìïöùíßá õðÜñ-÷åé ãéá ôç ÷ñÞóç ôùí êïñôéêïåéäþí óå áóèåíåßò ðïõ ðá-ñïõóéÜæïíôáé ìå íüóï óôáäßïõ ÉÉ Þ ÉÉÉ14 . Ç äïóïëïãßáåßíáé 1 mg/kg/24ùñï ðñåäíéæüíçò Þ äåîáìåèáæüíç 8-16mg/24ùñï. Ç äüóç áõôÞ äéáôçñåßôáé ãéá 3-6 åâäïìÜäåòêáé ìåôÜ âáèìéáßá ìåéþíåôáé óå 2-4 åâäïìÜäåò.

ÓõìðåñáóìáôéêÜ ç ðôþóç ôïõ åðéðÝäïõ óõíåßäçóçò

SUMMARY

Communicating hydrocephalus and severe hyponatremia in a patient with tuberculous meningitis

H. Sinani, F. Tsidemiadou, M. Michalia, K. Roukas, A. Koutsikou,G. Pantazis, F. Klouva-Molyvda

A case of miliary tuberculosis, tuberculous meningitis and severe hyponatremia, in a 19 year old manfrom Pakistan, is presented. The patient was admitted comatose to the ICU. A CT scan of the brainrevealed a communicating hydrocephalus and external ventricular drainage was performed.Hydrocephalus is a common complication of tuberculous meningitis, and may be even fatal if leftuntreated. External ventricular drainage has both therapeutic and predicting value for the benefit ofshunt surgery. Prompt ventriculoperitoneal shunting improves outcome, particularly in those patientswho present with minimal neurological deficit. Neurological deterioration occurring in a patient undertreatment for tuberculous meningitis may have various causes and always requires urgent radiologicalassessment. Pneumon 2003, 16(1):74-79.


1. MC Raviglione, DE Snider, A Kochi. Global epidemi-ology of tuberculosis. Morbidity and mortality of a worldwide epidemic. JAMA 1995; 273:220-6

2. D Bouros, J Demoiliopoulos, P Panagou, N Yiatromano-lakis, M Moschos, A Paraskeyopoulos, D Demoiliopou-los, N Siafakas. Incidence of tuberculosis in Greek armedforces from 1965-1993. Respiration 1995; 62:336-340.

3. Ravindra Kumar Garg. Tuberculosis of the central ner-vous system. Postgrad. Med. J. 1999; 75:133-140.

4. PM Small, PC Hopewell, SP Singh et al. The epidemiol-ogy of tuberculosis in San Francisco: a population- basedstudy using conventional and molecular methods. N EnglJ Med 1994; 330:1703-9.

5. UK Misra, J Kalita, M Srivastava, et al. Prognosis of tu-berculous meningitis a multivariate analysis. J NeurolSci 1996; 137:57-61.

6. G Thwaites, TTH Chau, NTH Mai, F Drobniewski, KMcAdam, J Farrar. Tuberculous meningitis. J Neurol.Neurosurg. Psychiatry 2000; 68:289-299.

7. PM Udani, PK Dastur. Tuberculous encephalopathywith and without meningitis: clinical features and patho-logical correlations. J Neurol Sci 1970; 10:541-61.

8. R Palur, V Rajshenkhar, MJ Chandy. Shunt surgery forhydrocephalus in tuberculous meningitis: a long termfollow up study. J Neurosurg 1991; 74:64-9.

9. JM Mathew, V Rajshenkhar, MJ Chandy. Shunt surgeryin poor grade patients with tuberculous meningitis and


hydrocephalus: effects of response to external ventricu-lar drainage and other variables on long term outcome.J Neurol Neurosurg Psychiatry 1998; 65:115-118.

10. A Ross Hill, J Uribari, J Mann, T Berl. Altered watermetabolism in tuberculosis: role of Vasopressin. TheAmerican Journal of Medicine 1990; 88:357-364.

11. PK Narotam, M Kemp, R Buck, E Gouws, JR VanDellen, KD Bhoola. Hyponatremic Natriuretic syndromein tuberculous meningitis. The probable role of AtrialNatriuretic peptide. Neurosurgery 1994; 34(6):982-988.

12. P F Barnes. Rapid diagnostic tests for tuberculosis.Progress but no gold standard. Am J Respir Crit CareMed 1997; 155:1497-1498.

13. Joint Tuberculosis Committee of the British ThoracicSociety. Chemotherapy and management of tuberculo-sis in the United Kingdom : recommendations 1998.Thorax 1998; 53:536-48.

14. PK Coyle. Glucocorticoids in central nervous systembacterial infection. Arch Neurol 1999; 56:796-801.


Èùñáêï÷åéñïõñãéêÞ åîáßñåóç Ýêôïðïõ áäåíþìáôïòðáñáèõñåïåéäïýò

ÐÅÑÉËÇØÇ. Óôçí ðëåéïíüôçôÜ ôïõò ôá ðáñáèõñåïåéäéêÜ áäå-íþìáôá åîáéñïýíôáé ÷åéñïõñãéêÜ äéá ôçò ôñá÷çëéêÞò ôïìÞò. ÔáÝêôïðá áäåíþìáôá, ðïõ âñßóêïíôáé óôï ìåóïèùñÜêéï áöáéñïý-íôáé ìå ìÝóç óôåñíïôïìÞ Þ èùñáêïôïìÞ. Ôá ôåëåõôáßá ÷ñüíéá åß-íáé äõíáôüí íá åîáéñåèïýí ìå èùñáêïóêïðéêÞ ÷åéñïõñãéêÞ. Ðëåï-íåêôåß áõôÞ ç ôå÷íéêÞ ëüãù ôçò ìéêñüôåñçò íïóçñüôçôáò ðïõðáñïõóéÜæåé. Ðñüêåéôáé ãéá ìéá ðåñßðôùóç áóèåíïýò ìå ÷ñüíéáíåöñéêÞ áíåðÜñêåéá êáé ôñéôïðáèÞ õðåñðáñáèõñåïåéäéóìü. ÔïáäÝíùìá åíôïðßóôçêå ìå áîïíéêÞ ôïìïãñáößá èþñáêïò üðïõ ìüñ-öùìá (ðéèáíü Ýêôïðï áäÝíùìá ðáñáèõñåïåéäïýò) áíåõñÝèç óôïìåóïèùñÜêéï ìåôáîý ôçò áñéóôåñÞò õðïêëåéäßïõ êáé ôçò óýóôïé-÷çò êáñùôßäáò. ÁöáéñÝèçêå èùñáêïóêïðéêÜ. Ï áóèåíÞò ðáñÝìåé-íå óôï Íïóïêïìåßï 24 þñåò. Ç áðïêáôÜóôáóç ôùí ôéìþí ôçò ðá-ñáèïñìüíçò êáé ôïõ áóâåóôßïõ óôï áßìá, êáèþò êáé ç ìåôåã÷åé-ñçôéêÞ áîïíéêÞ ôïìïãñáößá èþñáêïò åðéâåâáéþíïõí ôçí áðïôå-ëåóìáôéêüôçôá ôçò èùñáêïóêïðéêÞò åêôïìÞò. Ðíåýìùí 2003,16(1):80-85.

ÕËÉÊÏ

Ðñüêåéôáé ãéá áóèåíÞ 47 åôþí, ï ïðïßoò áðü 10åôßáò, õðïâÜëëåôáé óåáéìïäõÀëéóç. Ðñüóöáôá äéåðéóôþèç üôé ðáñïõóéÜæåé ôñéôïðáèÞ õðåñðá-ñáèõñåïåéäéóìü, ïöåéëüìåíï óôç ÷ñüíéá íåöñéêÞ áíåðÜñêåéá.

Áðü ôéò åîåôÜóåéò áßìáôïò ôá åðßðåäá Ca++ óôïí ïññü ôïõ áßìáôïòâñÝèçêáí åëáöñþò áõîçìÝíá êáé óõãêåêñéìÝíá, 11.5mg/dl (ö.ô. 8-10mg/dl), üðùò åðßóçò êáé áõôÜ ôçò ðáñáèïñìüíçò (620 pg/ml ìå ö.ô. 50-300 g/ml) êáé ôïõ öùóöüñïõ (7 mg/dl ìå ö.ô. 2.5-4.5 mg/dl). Ìå áõôÜ ôáäåäïìÝíá ï áóèåíÞò äéåñåõíÞèçêå ðñïêåéìÝíïõ íá åðéâåâáéùèåß çðáñïõóßá ðéèáíïý áäåíþìáôïò ðáñáèõñåïåéäïýò.

Ç áîïíéêÞ ôïìïãñáößá èþñáêïò áíÝäåéîå ôï Ýêôïðï ðáñáèõñåïåéäÝòáäÝíùìá óôï ìåóïèùñÜêéï ùò óõìðáãÝò ìüñöùìá äéáìÝôñïõ 2cm åðß

Ä. ÃáñìðÞò,Ê. ÇëéÜäçò,Á. ×áôæßíçò,Á. Óôáèïõëüðïõëïò,Á. ÊïíôáîÞò

Èùñáêï÷åéñïõñãéêÞ ÊëéíéêÞ Ä.È.Ê.Á. ́ ´ÕÃÅÉÁ´´

ËÝîåéò - êëåéäéÜ: Ýêôïðï áäÝíùìá ðáñáèõñåïåé-äïýò, VATS

Áëëçëïãñáößá:ÈåñáðåõôÞñéï "Õãåßá", ÁèÞíá


ôïõ áïñôéêïý ôüîïõ, ìåôáîý ôùí åêöýóåùí ôçò áñéóôå-ñÞò õðïêëåéäßïõ áñôçñßáò êáé ôçò áñéóôåñÞò êáñùôßäïò(Åéêüíá 1).

Ôï óðéíèçñïãñÜöçìá 99m Tc Sestamibi åðéâåâáßù-óå ôï åýñçìá ôçò áîïíéêÞò ôïìïãñáößáò êáé áðïöáóß-óôçêå ç ÷åéñïõñãéêÞ åîáßñåóç ôïõ ìå ôç ìÝèïäï ôçòèùñáêïóêïðéêÞò ÷åéñïõñãéêÞò. Ôçí ðñïçãïýìåíç çìÝ-ñá ôçò åðÝìâáóçò, ï áóèåíÞò õðåâëÞèç êáíïíéêÜ óôçíêáèçìåñéíÜ óå áéìïäéûëéóç óôï Íïóïêïìåßï ôçò ðåñéï-÷Þò ôïõ.

Óôç óõíÝ÷åéá åéóÞ÷èç óôï Íïóïêïìåßï ìáò êáé ìåôÜáðü ðñïåã÷åéñçôéêü Ýëåã÷ï åðéâåâáéþèçêáí ïé áõîç-ìÝíåò ôéìÝò ôïõ áóâåóôßïõ 12 mg/dl êáé ôçò ðáñáèïñìü-íçò 650 pg/ml. Ï áóèåíÞò ôçí åðïìÝíç çìÝñá õðåâëÞèçóå èùñáêïóêïðéêÞ áöáßñåóç ôïõ åí ëüãù ìïñöþìáôïò.Ôï ïãêßäéï åóôÜëç ðñïò ðáèïëïãïáíáôïìéêÞ åîÝôáóç,üðïõ ôåëéêÜ êáé åôÝèç ç äéÜãíùóç ôïõ Ýêôïðïõ ðáñá-èõñåïåéäéêïý áäåíþìáôïò. Ôá ìåôåã÷åéñçôéêÜ áðïôåëÝ-óìáôá áßìáôïò ãéá ôï Ca++ Þôáí 8,8mg/dl, åíþ ïé ôéìÝòôçò ðáñáèïñìüíçò åðÝóôñåøáí óôá öõóéïëïãéêÜ üñéá.Ç áîïíéêÞ ôïìïãñáößá èþñáêïò, ðïõ Ýãéíå ìåôåã÷åé-ñçôéêÜ (4 ìÞíåò ìåôÜ ôçí åðÝìâáóç), Ýäåéîå ôçí áðïõ-óßá ôïõ åí ëüãù ðñïåã÷åéñçôéêïý áðåéêïíéóôéêïý åõñÞ-ìáôïò (Åéêüíá 2).

Åéêüíá 2. Ìåôåã÷åéñçôéêÞ CT èþñáêïò ðïõ äåß÷íåé ôçí áðïõ-óßá ôïõ áäåíþìáôïò

Åéêüíá 1. Ðñïåã÷åéñçôéêÞ CT èþñáêïò ðïõ äåß÷íåé ôç èÝóçôïõ áäåíþìáôïò

ÔÅ×ÍÉÊÇ

Ç ÈùñáêïóêïðéêÞ ÷åéñïõñãéêÞ (Video AssistedThoracic Surgery) Ýãéíå õðü ãåíéêÞ áíáéóèçóßá, ìå ôç÷ñÞóç ôïõ åíäïôñá÷åéáêïý äéðëïý áõëïý óùëÞíá, ìå ôçâïÞèåéá ôïõ åéêïíïóêïðßïõ. Ï áóèåíÞò ôÝèçêå óå ðëá-ãßá èÝóç áñéóôåñÞò èùñáêïôïìÞò. Áñ÷éêÜ Ýãéíå ôïìÞ1cm óôï 6ï ìåóïðëåýñéï äéÜóôçìá óôç ìÝóç ìáó÷áëéáßáãñáììÞ. ÌåôÜ ôïí áðïêëåéóìü ôïõ áñéóôåñïý êýñéïõâñüã÷ïõ êáé ôçí áôåëåêôáóßá ôïõ óõóôïß÷ïõ ðíåýìïíá,åéóÞ÷èç ç camera ãéá ôçí åðéóêüðçóç ôçò èùñáêéêÞòêïéëüôçôáò. ÁíåõñÝèç ìüñöùìá õðü ôïí ìåóïèùñáêé-êü õðåæùêüôá, åðß ôïõ áïñôéêïý ôüîïõ, ìåôáîý ôùí åê-öýóåùí ôçò áñéóôåñÞò êáñùôßäáò êáé ôçò áñéóôåñÞòõðïêëåéäßïõ áñôçñßáò. Ï ëïéðüò Ýëåã÷ïò ôïõ çìéèùñá-êßïõ áðÝâç áñíçôéêüò (Åéêüíá 3).

Ç äåýôåñç ôïìÞ ìÞêïõò 2cm Ýãéíå óôçí ðñüóèéá ìá-ó÷áëéáßá ãñáììÞ, åíþ ìéá ôñßôç ôïìÞ ìÞêïõò 0,5cm Ýãé-íå óôçí ïðßóèéá ìáó÷áëéáßá ãñáììÞ, óôï 5ï ìåóïðëåý-ñéï äéÜóôçìá, ìå ôçí êáèïäÞãçóç ôïõ åéêïíïóêïðßïõ.

ÌåôÜ ôç äéÜíïéîç ôïõ ìåóïèùñáêéêïý õðåæùêüôá,ôï áäÝíùìá ðáñáóêåõÜóôçêå åðéìåëþò ÷ùñßò ñÞîç ôçòêÜøáò ôïõ, äéçíýæïíôáò ôïõò ðÝñéî áõôïý éóôïýò. ÓôçíðáñáóêåõÞ óõíÝâáëå ôï ó÷åôéêÜ áíÝíäïôï ôùí åêáôÝ-ñùèåí áõôïý áããåßùí. ÌåôÜ ôçí ðëÞñç ðáñáóêåõÞ ôïõáöáéñÝèçêå êáé ìå ôç ÷ñÞóç åéäéêïý óÜêïõ, åîÞëèå äéáôçò ìåãáëýôåñçò ôïìÞò (Åéêüíá 4). Ç ÷ñÞóç åéäéêïý


Åéêüíá 3. ÈùñáêïóêïðéêÞ äéåã÷åéñçôéêÞ ëÞøç ôçò èÝóçò ôïõáäåíþìáôïò

Åéêüíá 4. Äéåã÷åéñçôéêÞ ëÞøç êáôÜ ôçí Ýîïäï ôïõ áäåíþìá-ôïò áðü ôç èùñáêéêÞ êïéëüôçôá

óÜêïõ "endo bag" óõìâÜëëåé óôçí áðïöõãÞ åìöõôåý-óåùí êõôôÜñùí óôç äéáäñïìÞ åîüäïõ ôïõ ðáñáóêåõÜ-óìáôïò áðü ôç èùñáêéêÞ êïéëüôçôá.

¸íáò óùëÞíáò ðáñï÷Ýôåõóçò èþñáêïò ðñïùèÞèç-êå óôï ýøïò ôçò êïñõöÞò ôïõ ðíåýìïíá äéá ôçò ôïìÞòðïõ åß÷å ãßíåé óôç ìÝóç ìáó÷áëéáßá ðåñéï÷Þ ãéá ôçí åé-óáãùãÞ ôçò camera. Óôç óõíÝ÷åéá ï áðïêëåéóìüò ôïõáñéóôåñïý êýñéïõ âñüã÷ïõ äéáêüðçêå êáé ï ðíåýìïíáòåêðôý÷èçêå. Áöïý óõíåññÜöçóáí êáé ïé Üëëåò äõï ôï-ìÝò, ï áóèåíÞò áíÝíçøå ïìáëþò êáé ïäçãÞèçêå óôï èÜ-ëáìï íïóçëåßáò ôïõ. Ï óùëÞíáò ðáñï÷Ýôåõóçò èþñá-êïò áöáéñÝèçêå ôï åðüìåíï ðñùß ìåôÜ áðü áêôéíïãñá-ößá èþñáêïò. Áðü ôçí áêôéíïãñáößá åðéâåâáéþèçêå çðëÞñçò Ýêðôõîç ôïõ áñéóôåñïý ðíåýìïíá, ÷ùñßò ôçíýðáñîç ðëåõñéôéêÞò óõëëïãÞò Þ êÜðïéïõ âáèìïý áôå-ëåêôáóßáò ôïõ ðíåõìïíéêïý ðáñåã÷ýìáôïò. Ï áóèåíÞòåîÞëèå ôçí ßäéá çìÝñá óå êáëÞ ãåíéêÞ êáôÜóôáóç.

Ç ìáêñïóêïðéêÞ ðáèïëïãïáíáôïìéêÞ åîÝôáóç Ýäåé-îå üôé åðñüêåéôï ãéá ìüñöùìá ìåãßóôçò äéáìÝôñïõ 2 åê.êáé âÜñïõò 2,5 ãñáììáñßùí. ÌéêñïóêïðéêÜ áíôéóôïé-÷åß óå õðåñðëáóôéêü ðáñáèõñåïåéäéêü éóôü ðïõ áðïôå-ëåßôáé êõñßùò áðü èåìÝëéá êýôôáñá êáé åóôéáêÜ áðüïîýöéëá êáé äéáõãÞ êýôôáñá (Åéêüíá 5), ðïõ áíáðôýó-óïíôáé äéÜ÷õôá êáé ó÷çìáôßæïõí íçóßäåò ìåôáîý ôùíïðïßùí ðáñåìâÜëëïíôáé éíþäç äéáöñáãìÜôéá. Óõìðå-ñáóìáôéêÜ ëïéðüí åðñüêåéôï ãéá õðåñðëáóßá ðáñáèõ-ñåïåéäéêïý éóôïý êõñßùò èåìåëßùí êõôôÜñùí, ãåãïíüòðïõ åðéâåâáßùóå ôåëéêÜ ôç äéÜãíùóç.

Åéêüíá 5. Ôá ïîýöéëá êýôôáñá.

ÓÕÆÇÔÇÓÇ

Ïé ðáñáèõñåïåéäåßò áäÝíåò åßíáé óõíÞèùò ôÝóóåñéòêáé âñßóêïíôáé ïðéóèïðëáãßùò ôçò êÜøáò ôïõ èõñåïåé-äïýò áäÝíá. Ôï Üíù æåýãïò ôùí ðáñáèõñåïåéäþí åßíáéóõ÷íÜ üðéóèåí ôïõ Üíù ëïâïý ôïõ èõñåïåéäïýò. Ìðï-ñïýí üìùò êáé íá âñåèïýí êáé óôç ðëáãßá åðéöÜíåéáôïõ ôñá÷çëéêïý ïéóïöÜãïõ. Ôï êÜôù æåýãïò ôùí ðáñá-èõñåïåéäþí áäÝíùí óõíÞèùò âñßóêåôáé óôï êáôþôåñïóçìåßï ïðéóèïðëáãßùò ôçò êÜøáò ôïõ èõñåïåéäïýò áäÝ-íá. Ç áéìÜôùóç ôïõò åîáóöáëßæåôáé áðü ôçí êÜôù èõ-ñåïåéäéêÞ áñôçñßá åíþ ç íåýñùóÞ ôïõò ðñïÝñ÷åôáé áðüôï óõìðáèçôéêü óôÝëå÷ïò êáé åéäéêüôåñá áðü ôï Üíù êáéìÝóï áõ÷åíéêü ãÜããëéï. Ïé êÜôù ðáñáèõñåïåéäåßò áäÝ-íåò, åìâñõïëïãéêÜ, ðñïÝñ÷ïíôáé áðü ôïí 3ï âñáã÷éáêüèýëáêï, ìáæß ìå ôïí èýìï. Áêïëïýèùò, áíáðôýóóïíôáéìáæß ìå ôïí èýìï áäÝíá êáé êáôåâáßíïõí ðñïò ôï ðñü-


ôïò åßíáé ôï óðéíèçñïãñÜöçìá èáëßïõ-ôå÷íçôßïõ (99mc

Tc Sestamibi) êáé ç ìáãíçôéêÞ ôïìïãñáößá. Ç ìáãíçôé-êÞ ôïìïãñáößá, óõãêñéíüìåíç ìå ôçí áîïíéêÞ, åßíáéáêñéâÝóôåñç ãéá ôïí åíôïðéóìü ôùí ðáñáèõñåïåéäþíáäÝíùí. Óáöþò üìùò õðåñôåñåß üëùí ôùí ìåèüäùí ôïóðéíèçñïãñÜöçìá èáëßïõ- ôå÷íçôßïõ (99mc Tc Sesta-mibi).

ÁíáóôïëÞ ôçò ëåéôïõñãßáò ôïõ ðáñáèõñåïåéäéêïýáäåíþìáôïò, ìðïñåß íá åðéôåõ÷èåß ìå ôç ìÝèïäï ôïõåìâïëéóìïý ôïõ áããåßïõ ðïõ ôï ôñïöïäïôåß. Ïé åðéðëï-êÝò, üìùò, áõôÞò ôçò ìåèüäïõ åßíáé óçìáíôéêÝò, üðùòðáñïäéêÞ ôýöëùóç, çìéðëçãßá ê.ëð., åíþ ôá ðïóïóôÜáðïôõ÷ßáò ôçò ìåèüäïõ áõôÞò åßíáé õøçëÜ (ðåñßðïõ40%). ÅðéðëÝïí, ìå ôç ìÝèïäï áõôÞ äåí õðÜñ÷åé äõíá-ôüôçôá áõôïìåôáìüó÷åõóçò ôïõ åîáéñåèÝíôïò ðáñáèõ-ñåïåéäéêïý áäåíþìáôïò óå ðåñßðôùóç õðïðáñáèõñåïåé-äéóìïý5.

Ç åêôïìÞ ôùí ðáñáèõñåïåéäéêþí áäåíùìÜôùí, áíá-ëüãùò ôçò áíáôïìéêÞò èÝóçò åíôüðéóÞò ôïõò, åßíáé åöé-êôÞ äéá ôçò ôñá÷çëéêÞò ôïìÞò, ôçò óôåñíïôïìÞò, ôçò èù-ñáêïôïìÞò êáé ìå ôç ìÝèïäï ôçò èùñáêïóêïðéêÞò ÷åé-ñïõñãéêÞò (VATS).

Óôçí ðëåéïíüôçôá ôïõò, ôá ðáñáèõñåïåéäéêÜ áäåíþ-ìáôá ìðïñïýí íá åîáéñåèïýí äéá ôçò ôñá÷çëéêÞò ôïìÞò.Óå ìéá ìåëÝôç ôïõ Russell 6 êáé ôùí óõíåñãáôþí ôïõ, óå38 áóèåíåßò áöáéñÝèçêáí ìå óôåñíéêÞ ðñïóðÝëáóç ðá-ñáèõñåïåéäéêÜ áäåíþìáôá êáé ç íïóçñüôçôá Þôáí õøç-ëÞ, áíåñ÷üìåíç óå ðåñßðïõ 29%. Óå áõôÞí ðåñéëáìâÜ-íïíôáí: á) åðéðëïêÝò åê ôïõ èþñáêïò üðùò ç ðëåõñéôé-êÞ óõëëïãÞ (10,5%), ï ðíåõìïèþñáêáò (2,6%) êáé çðíåõìïíßá (7,9%) êáé â) åê ôïõ ôñáýìáôïò, áéìÜôùìáêáé ðñïóèßá ìåóïèùñáêßôéäá óå ðïóïóôü 2,6%. ̧ íáòáóèåíÞò ðáñïõóßáóå ìüíéìç ðÜñåóç öùíçôéêþí ÷ïñ-äþí, 2 áóèåíåßò ðáñïäéêÞ êïëðéêÞ ìáñìáñõãÞ êáé ÝíáòáóèåíÞò åí ôù âÜèåé öëåâéêÞ èñüìâùóç. Óå ìåëÝôç ôïõConn7, óå 4 áðü ôïõò 21 áóèåíåßò áíáöÝñïíôáé åðéðëï-êÝò áðü ôç óôåñíïôïìÞ óå ðïóïóôü 19%. Ïé äõï ðáñïõ-óßáóáí ðëåõñéôéêÞ óõëëïãÞ, ï ôñßôïò ÷ïíäñßôéäá ôçò îé-öïåéäïýò áðüöõóçò êáé ï ôÝôáñôïò èñüìâùóç ôçò áñé-óôåñÞò õðïêëåéäßïõ. Èá ðñÝðåé åðßóçò íá ôïíéóèåß ç ìå-ãÜëç áðïôõ÷ßá (36%) ôçò äéåã÷åéñçôéêÞò åíôüðéóçò ôïõåêôüðïõ áäåíþìáôïò ìå óôåñíïôïìÞ, üôáí äåí Ý÷åé ãß-íåé ðñïåã÷åéñçôéêÞ åíôüðéóç8.

Ç ìåóïèùñáêïóêüðçóç11 êáé ç ðñüóèéá ìåóïèùñá-êïôïìÞ12 Ý÷ïõí ðåñéãñáöåß ùò åíáëëáêôéêÝò ðñïóåããß-

óèéï ìåóïèùñÜêéï.ÌáêñïóêïðéêÜ, óõ÷íÜ ðåñéâÜëëïíôáé áðü Ýíá ëé-

ðþäåò ðåñßâëçìá êáé öÝñïõí ôá ÷áñáêôçñéóôéêÜ êïê-êßá Üëáôïò óôçí åðéöÜíåéá ôïõò. Ôï ó÷Þìá êáé ç ìáë-èáêÞ óýóôáóÞ ôïõò, ôïõò äéáêñßíåé áðü ôïí ðÝñéî ëéðþ-äç éóôü êáé ôïõò ëåìöáäÝíåò. ÌéêñïóêïðéêÜ, ïé ðáñá-èõñåïåéäåßò áäÝíåò ÷áñáêôçñßæïíôáé áðü ôá èåìÝëéá êáéôá ïîýöéëá êýôôáñá. Óå öõóéïëïãéêïýò ðáñáèõñåïåé-äåßò õðÜñ÷ïõí êáé ôá äéáõãÞ êýôôáñá, ðïõ åßíáé ìåãÜ-ëá êáé áõîÜíïõí óçìáíôéêÜ óå ïñéóìÝíåò ðåñéðôþóåéòõðåñðëáóßáò ôùí ðáñáèõñåïåéäþí, üðùò êáé óôçí ðå-ñßðôùóç ôïõ áóèåíÞ ìáò.

¼ôáí Ýíáò ðáñáèõñåïåéäÞò áäÝíáò äåí âñßóêåôáéóôç óõíÞèç áíáôïìéêÞ èÝóç, ôüôå ðéèáíüôáôá âñßóêå-ôáé óôï ðñüóèéï ìåóïèùñÜêéï êáé ìÜëéóôá êïíôÜ óôïèýìï áäÝíá. ̧ íáò åõìåãÝèçò ðáñáèõñåïåéäÞò áäÝíáò,ðïõ åíôïðßæåôáé áñ÷éêÜ óå óõíÞèç áíáôïìéêÞ èÝóç, ìðï-ñåß íá ìåôáêéíçèåß ðñïò ôç èùñáêéêÞ êïéëüôçôá, åßôååîáéôßáò ôïõ âÜñïõò ôïõ, åßôå åîáéôßáò ôçò áñíçôéêÞòåíäïèùñáêéêÞò ðßåóçò.

Óå ìåãÜëç áíáäñïìéêÞ ìåëÝôç ôïõ Wang, áðü 21Ýêôïðá ðáñáèõñåïåéäéêÜ áäåíþìáôá, ðïõ âñßóêïíôáíóôï ìåóïèùñÜêéï ðïóïóôü 67% áõôþí âñßóêïíôáí ãýñùáðü ôï èýìï áäÝíá1. Ï êáôþôåñïò ðáñáèõñåïåéäÞò áäÝ-íáò óõíÞèùò âñßóêåôáé ìðñïóôÜ áðü ôï ðáëßíäñïìï ëá-ñõããéêü íåýñï êáé êÜôù áðü ôçí Ýêöõóç ôçò èõñåïåéäé-êÞò áñôçñßáò. Ôï 1932 ï Dr Edward Churchill Þôáí ïðñþôïò ðïõ áíáãíþñéóå üôé ôá õðåñëåéôïõñãéêÜ áäå-íþìáôá ôùí ðáñáèõñåïåéäþí ìðïñïýí íá âñßóêïíôáéâáèéÜ ìÝóá óôï ìåóïèùñÜêéï. Ï áóèåíÞò CaptáinCharles Martell 2 Þôáí ï ðñþôïò ðïõ õðåâëÞèç óå (6)Ýîé áíåðéôõ÷åßò ÷åéñïõñãéêÝò äéåñåõíÞóåéò ãéá Ýêôïðïðáñáèõñåïåéäéêü áäÝíùìá. Ç Ýâäïìç åðÝìâáóç Ýãéíåìå ìÝóç óôåñíïôïìÞ, êáôÜ ôçí ïðïßá áíåõñÝèç ôåëéêÜêáé åîáéñÝèåé ôï Ýêôïðï ðáñáèõñåïåéäÝò áäÝíùìá3.

Åêôéìþíôáò üôé ôï ðïóïóôü åêôüðïõ ìåóïèùñáêéêïýðáñáèõñåïåéäÞ áäÝíá4 åßíáé ìéêñüôåñï ôïõ 2%, óõíÞ-èùò äåí ãßíåôáé áðåéêïíéóôéêÞ äéåñåýíçóç ôïõ ìåóïèù-ñáêßïõ, ðáñÜ ìüíï ôñá÷çëéêÞ. Ïé åíôïðéóìÝíåò üìùòëÞøåéò ãßíïíôáé áðáñáßôçôåò, üôáí ç ôñá÷çëéêÞ äéåñåý-íçóç áðïôý÷åé. Ïé ðáñáèõñåïåéäåßò áäÝíåò ðïõ åßíáéìåãáëýôåñïé áðü 1,5cm öáßíïíôáé åýêïëá óôçí áîïíé-êÞ ôïìïãñáößá, åíþ ïé õðüëïéðïé ðïõ åßíáé ìéêñüôåñïõìåãÝèïõò åßíáé äýóêïëá íá áíáäåé÷èïýí.

Óýã÷ñïíåò ìÝèïäïé ãéá ôçí áíåýñåóç ôïõ áäåíþìá-


óôåß ðñïåã÷åéñçôéêÜ êáé ìå áêñßâåéá ç èÝóç ôïõ Ýêôï-ðïõ ðáñáèõñåïåéäéêïý áäåíþìáôïò.

ÓõìðåñáóìáôéêÜ, êáôÜ ôïí ôñéôïðáèÞ õðåñðáñáèõ-ñåïåéäéóìü, üôáí ôï Ýêôïðï ìåóïèùñáêéêü ðáñáèõ-ñåïåéäÝò áäÝíùìá âñßóêåôáé óå ôÝôïéá áíáôïìéêÞ èÝóç,þóôå íá ÷ñÞæåé äéáèùñáêéêÞò ðñïóðÝëáóçò ãéá ôçíáöáßñåóç ôïõ, ç èùñáêïóêïðéêÞ ÷åéñïõñãéêÞ åßíáé çìÝèïäïò åêëïãÞò. ¼óïí áöïñÜ óôïí ìåôåã÷åéñçôéêüðüíï õðåñôåñåß ôçò êëáóóéêÞò èùñáêïôïìÞò14, åíþ óõã-÷ñüíùò Ý÷åé êáëýôåñï êïóìçôéêü áðïôÝëåóìá óôïíáóèåíÞ, åßíáé äå ôï ßäéï áóöáëÞò êáé áðïôåëåóìáôéêÞüôáí ãßíåôáé óå åîåéäéêåõìÝíá êÝíôñá.

óåéò ãéá ôçí åêôïìÞ ôùí ðáñáèõñåïåéäéêþí áäåíùìÜ-ôùí, ôá ïðïßá âñßóêïíôáé óôï ðñüóèéï êáé Üíù ìåóï-èùñÜêéï.

Óôïí óõãêåêñéìÝíï áóèåíÞ ôçò ðáñïõóßáóÞò ìáò, çèÝóç áðáéôïýóå äéáèùñáêéêÞ ðñïóðÝëáóç. Ãéá ôï ëüãïáõôü, åðéëÝ÷ôçêå ç ðëÝïí áíþäõíïò êáé åðùöåëÞò ìÝ-èïäïò ãéá ôçí åêôïìÞ ôïõ åíôïðéóìÝíïõ Ýêôïðïõ ðáñá-èõñåïåéäÞ áäÝíá êáé óõãêåêñéìÝíá, ç èùñáêïóêïðéêÞ÷åéñïõñãéêÞ (VATS)13. Óôç äéåèíÞ âéâëéïãñáößá Ý÷ïõíÞäç áíáöåñèåß ïêôþ ðåñéðôþóåéò áäåíùìÜôùí ðáñá-èõñåïåéäþí, ôá ïðïßá åîáéñÝèçêáí ìå ôç èùñáêïóêï-ðéêÞ ìÝèïäï9 êáé óå üëåò ôéò ðåñéðôþóåéò åß÷å êáèïñé-

SUMMARY

Thoracoscopic excision of ectopic parathyroid adenoma

D. Garbis, K. Iliadis, A. Hatzinis, A. Stathoulopoulos, A. Kontaxis

Thoracic Surgery Department, Diagnostic & Therapeutic Center of Athens ́ ´HYGEIA´´

The vast majority of parathyroid adenomas are excised through a cervical incision. The ectopic ones,which are usually are localized in the mediastinum, are excised through sternotomy or thoracotomy.In recent years, it has been possible to resect this kind of adenomas with the use of video assistedthoracoscopic surgery (VATS), this technique offering the advantage of lower morbidity. We describea case of a patient with end stage renal failure and tertiary hyperparathyroidism with ectopic parathyroidadenoma localized on the aortic arch, between the origin of the left carotid artery and left subclavianartery. The adenoma was excised using VATS and the patient was discharged on the first postoperativeday following excision. CT scans, parathormone and Ca blood levels returned to normal. Pneumon2003, 16(1):80-85.

Key words: ectopic parathyroid adenoma, VATS


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2. Bauer W, Federman DD. Hyperparathyroidism epito-mized the case of Captain Charles E. Martell. Metabo-lism 1962; 11:21-29.

3. Cope O. The story of hyperparathyroidis at the Massa-chusetts Gen. Hospital N Engl J Med 1966; 274:1174-1182.

4. Printz RA, Lonchyma V, Carnaille B, Wurtz A, ProyeC. Thoracoscopic excision of enlarged mediastinal par-athyroid. Surg. Dec 1994; Vol 116, Nr 6, 999-1004.

5. Heller JH, Miller LG, Erdman AW, Snyder HW, Bre-slau AN. Angiographic Ablation of Mediastinal Parathy-

roid Adenomas: Local Experience and Review of theLiterature. Dallas, Texas. Ann Journal of medicine Dec1994; Vol. 97, 529-534.

6. Rusell CR, Edis AJ, Scholz DA, et al. Mediastinal par-athyroid tumors: experience with 38 tumors requiringmediastinotomy for removal. Ann Surg 1981; 193:805-809.

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8. Clark OH. Mediastinal parathyroid. Tumors Arch Surg.Vol 123, Sept. 1988.

9. Knight R, Ratzer ER, Fenoglio ME, Moore JT. Thora-coscopic excision of mediastinal parathyroid adenomas:


a report of two cases and review of the literature. J AmColl Surg 1997; 185(5):481-5.

10. Medrano C, Hazerligg SR, Landreneau RJ, Boley TM,Shawgo T, Grasch A. Thoracoscopic resection of ectop-ic parathyroid glands. Ann Thorac Surg 2000 Jan; 69(1):221-3.

11. Ohno K, Kumata K, Yamasaki Y, Yamasaki H. Medi-astinoscopic extirpation of mediastinal ectopic parathy-roid gland. Ann Thorac Surg 1997 July; 64(1):238-40.

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anterior mediastinotomy. Mayo Clin Proc 1991; 66:1110-3.

13. Cirino LM, Milanez de Campos JR, Fernadez A, SamanoMN, Fernandez PP, Filomeno LT, Jatene FB. Diagno-sis and treatment of mediastinal tumors by thoracosco-py. Chest 2000 June; 117(6):1787-92.

14. Forster R, Storck M, Schafer R, Honig E, Lang G, Lie-wald F. Thoracoscopy versus thoracotomy: a prospec-tive comparison of trauma and quality of life. Langen-becks Arch Surg 2002 Apr; 387(1):32-6.

Ìåôáóôáôéêü ðáñáãáããëßùìá ðíåýìïíïòóå óõíäõáóìü ìå in situ âñïã÷ïãåíÝò êáñêßíùìá

Ê. Êáôóïýëçò1,Ã. Ðáðá÷ñÞóôïò2,È. Æáñáìðïýêáò3,È. Êïíôáêéþôçò1,Á. ÍáëìðÜíôçò1

ÐÅÑÉËÇØÇ. ÐáñïõóéÜæåôáé ðåñßðôùóç ìåôáóôáôéêïý ðáñáãáã-ãëéþìáôïò ðíåýìïíá óå óõíäõáóìü ìå in situ áíÜðôõîç âñïã÷ï-ãåíïýò êáñêßíïõ áðü ðëáêþäåò åðéèÞëéï óôï ßäéï óçìåßï. Ç ðñù-ôïðáèÞò åóôßá åíôïðéæüôáí óôïí ïðéóèïðåñéôïíáúêü ÷þñï êáé åß÷ååîáéñåèåß ÷åéñïõñãéêÜ ðñï åîáåôßáò, åíþ ç ìåôáóôáôéêÞ åóôßá Þôáíôõ÷áßï áêôéíïëïãéêü åýñçìá, ôï ïðïßï èåùñÞèçêå áñ÷éêÜ ùò ðñù-ôïðáèÝò íåüðëáóìá ðíåýìïíá. Ï áóèåíÞò áíôéìåôùðßóèçêå ìåëïâåêôïìÞ óôçí ïðïßá êáé áðïêáëýöèçêå ôï ðáñáãáããëßùìá. Ôáðáñáãáããëéþìáôá áðïôåëïýí üãêïõò ôïõ íåõñïåíäïêñéíéêïý óõ-óôÞìáôïò ìå óõ÷íüôåñç åíôüðéóç óôçí êïéëéáêÞ ÷þñá åíþ óôïõòðíåýìïíåò ç åíôüðéóç åßíáé óðÜíéá. Ìðïñåß íá åßíáé ëåéôïõñãé-êïß üôáí åêêñßíïõí êáôå÷ïëáìßíåò, ç èåñáðåßá ôïõò åßíáé ç ÷åé-ñïõñãéêÞ áöáßñåóç êáé ç ðñüãíùóÞ ôïõò èåùñåßôáé êáëÞ. Ðíåý-ìùí 2003, 16(1):86-90.

ÐÅÑÉÃÑÁÖH ÐÅÑÉÐÔÙÓÅÙÓ

Ðñüêåéôáé ãéá Üíäñá çëéêßáò 67 åôþí, êáðíéóôÞ (22 ðáêÝôá/Ýôç), ïïðïßïò åéóÞ÷èç óå ÐíåõìïíïëïãéêÞ êëéíéêÞ ãéá äéåñåýíçóç åðåéóïäßïõìå áéöíßäéá äýóðíïéá, ïðéóèïóôåñíéêü Üëãïò, åößäñùóç êáé ôÜóç ðñïòÝìåôï äéáñêåßáò 15 ëåðôþí, ôï ïðïßï õöÝèçêå êáôÜ ôçí åðüìåíç ìéóÞ þñá.

Áôïìéêü áíáìíçóôéêü: ÷åéñïõñãéêÞ åêôïìÞ äõï öïñÝò (Ýôç 1990 êáé1994) ðáñáãáããëéþìáôïò äåîéïý ïðéóèïðåñéôïíáúêïý ÷þñïõ åîïñìþìå-íïõ áðü ôï åðéíåöñßäéï, êáèþò êáé ÷åéñïõñãéêÞ åêôïìÞ ãéá ôïðéêÞ õðï-ôñïðÞ ðáñáãáããëéþìáôïò ôï 1996.

ÊëéíéêÞ åîÝôáóç: Üôïìï áñôéìåëÝò ìå êáëÞ èñÝøç, öõóéïëïãéêü áíá-ðíåõóôéêü øéèýñéóìá êáé öõóéïëïãéêÞ áñôçñéáêÞ ðßåóç êáé óöýîåéò (ìåôÜôçí ýöåóç ôùí áñ÷éêþí óõìðôùìÜôùí).

ÅñãáóôçñéáêÜ åõñÞìáôá: öõóéïëïãéêüò áéìáôïëïãéêüò Ýëåã÷ïò êáéáÝñéá áñôçñéáêïý áßìáôïò.

Áêôéíïãñáößá èþñáêïò: ïæþäçò óêßáóç ìå ó÷åôéêÜ óáöÞ üñéá óôïáñéóôåñü ìÝóï ðíåõìïíéêü ðåäßï ðáñáðõëáßùò (Åéêüíá 1).

Áëëçëïãñáößá:Êáôóïýëçò ÊùíóôáíôßíïòÇñïäüôïõ 38, 55133,Èåó/íßêçôçë: 2310-434605E-mail: [email protected]

1ÐíåõìïíïëïãéêÞ êëéíéêÞ 424 Ãåíéêïý ÓôñáôéùôéêïýÍïóïêïìåßïõ Èåó/íßêçò, 2Èùñáêï÷åéñïõñãéêü ÔìÞ-ìá 424 Ãåíéêïý Óôñáôéùôéêïý Íïóïêïìåßïõ Èåó/íß-êçò, 3ÅñãáóôÞñéï ÐáèïëïãéêÞò ÁíáôïìéêÞò Áñéóôï-ôåëåßïõ Ðáíåðéóôçìßïõ Èåó/íßêçò

ËÝîåéò - êëåéäéÜ: ðáñáãáããëßùìá, íåõñïåíäïêñé-íéêïß üãêïé, ìåôÜóôáóç ðíåýìïíá, âñïã÷ïãåíÞòêáñêßíïò



ôéêÞ ìÜæá óå õðïôìçìáôéêü ôïõ ðñïóèßïõ ôìçìáôéêïýôïõ áñéóôåñïý êõñßùò áíù ëïâáßïõ âñüã÷ïõ�. Áðü ôçâëÜâç åëÞöèçóáí âéïøßåò ëáâßäïò êáé åêðëýìáôá ãéáêõôôáñïëïãéêÞ åîÝôáóç.

Ç âéïøßá áíÝäåéîå �ðåñéï÷Þ ìå Ýêäçëç áôõðßá ôùíðõñÞíùí, áõîçìÝíï áñéèìü ìéôþóåùí êáé áóÜöåéá ôçòâáóéêÞò ìåìâñÜíçò, óôïé÷åßá éó÷õñÜ åíäåéêôéêÜ êáñêé-íþìáôïò ôïõ ðëáêþäïõò åðéèçëßïõ�. Óôáäéïðïßçóç ìåõðïëïãéóôéêÞ ôïìïãñáößá åãêåöÜëïõ, Üíù-êÜôù êïé-ëßáò êáé óðéíèçñïãñÜöçìá ïóôþí Þôáí áñíçôéêÞ ãéáäåõôåñïãåíåßò åíôïðßóåéò.

Ìå âÜóç ôá ðñïçãïýìåíá óôïé÷åßá ï áóèåíÞò äéá-êïìßóèçêå óôç Èùñáêï÷åéñïõñãéêÞ ÊëéíéêÞ üðïõ êáéõðïâëÞèçêå óå áñéóôåñÞ áíù ëïâåêôïìÞ ãéá ðñùôïðá-èÝò íåüðëáóìá ðíåýìïíïò. Ç ðáèïëïãïáíáôïìéêÞ åîÝ-ôáóç ôïõ ÷åéñïõñãéêïý ðáñáóêåõÜóìáôïò, ðñïò Ýêðëç-îç üëùí, áíÝäåéîå �ôõðéêÞ ìïñöïëïãßá êáé äéÜôáîç êõô-ôÜñùí öáéï÷ñùìïêõôôþìáôïò, ìå íåïðëáóìáôéêÜ êýô-ôáñá áñêåôÜ ìåãÜëá, ìå Ýíôïíá çùóéíüöéëï êõôôáñü-ðëáóìá, óõìðáãÞ äéÜôáîç êáé ðõñÞíåò õðïóôñüããõëïõòÞ åëáöñÜ ãùíéþäåéò ìÝôñéá âáèõ÷ñùìáôéêïýò� (Åéêü-íá 3). Ç ìåëÝôç ôïõ ðáñáóêåõÜóìáôïò ìå áíïóïúóôï-÷çìåßá Ýäåéîå èåôéêüôçôá ôùí íåïðëáóìáôéêþí êõôôÜ-ñùí óôç NSE (ÅéäéêÞ ÍåõñùíéêÞ ÅíïëÜóç) (Åéêüíá 4),åíþ Þôáí áñíçôéêÜ óôéò êåñáôßíåò åõñÝïò öÜóìáôïò óåáíôßèåóç ìå ôç èåôéêüôçôá åðéèçëéáêþí êõôôÜñùí êõ-øåëßäùí êáé âñïã÷éïëßùí (Åéêüíá 5). Óýóôïé÷á ðñïòôïí üãêï âñÝèçêå åðßóçò �ðëáêþäçò ìåôáðëáóßá óôïíâëåííïãüíï ôïõ âñüã÷ïõ ìå Ýêäçëç áôõðßá êáé áýîçóç

Åéêüíá 2. ÓõìðáãÞò åíäïðíåõìïíéêÞ ìÜæá óôçí áñéóôåñÞðýëç, óå åðáöÞ ìå ôçí áñéóôåñÞ ðíåõìïíéêÞ áñôçñßá

Åéêüíá 1. Ïæþäçò óêßáóç ðáñáðõëáßá áñéóôåñÜ

ÅëéêïåéäÞò õðïëïãéóôéêÞ ôïìïãñáößá èþñáêïò:�ÁñíçôéêÜ åõñÞìáôá ãéá ðíåõìïíéêÞ åìâïëÞ. Óõìðá-ãÞò åíäïðíåõìïíéêÞ ìÜæá óôçí áñéóôåñÞ ðíåõìïíéêÞðýëç óå åðáöÞ ìå ôçí áñéóôåñÞ ðíåõìïíéêÞ áñôçñßá.ÅõìåãÝèçò åìöõóçìáôéêÞ êýóôç ôïõ óõóôïß÷ïõ áíùðíåõìïíéêïý ëïâïý. ×ùñßò äéüãêùóç ëåìöáäÝíùí ìå-óïèùñáêßïõ. ×ùñßò õðåæùêïôéêÞ óõëëïãÞ. ×ùñßò äï-ñõöüñá åíäïðíåõìïíéêÜ ïæßäéá� (Åéêüíá 2).

Óçìåéþíåôáé üôé ç ðíåõìïíéêÞ áõôÞ óêßáóç èåùñÞ-èçêå ôõ÷áßï áêôéíïëïãéêü åýñçìá êáé äåí óõó÷åôßóèç-êå ìå ôçí áñ÷éêÞ óõìðôùìáôïëïãßá ôïõ áóèåíïýò çïðïßá áðïäüèçêå ðåñéóóüôåñï óå óôçèáã÷éêü åðåéóü-äéï. Ï áóèåíÞò õðïâëÞèçêå óå éíïïðôéêÞ âñïã÷ïóêü-ðçóç óôçí ïðïßá äéáðéóôþèçêå �ìéêñÞ óôéëðíÞ åîùöõ-

Åéêüíá 3. ÔõðéêÞ ìïñöïëïãßá êáé äéÜôáîç êõôôÜñùí öáéï-÷ñùìïêõôôþìáôïò (Ç=Å x 200)


Åéêüíá 4. Èåôéêüôçôá ôùí íåïðëáóìáôéêþí êõôôÜñùí óôçíNSE (Áíïóïúóôï÷çìåßá x 200)

Åéêüíá 5. Ôá íåïðëáóìáôéêÜ êýôôáñá åßíáé áñíçôéêÜ óôéòêåñáôßíåò åõñÝïò öÜóìáôïò óå áíôßèåóç ìå ôçí èåôéêüôçôáåðéèçëéáêþí êõôôÜñùí-âñïã÷éïëßùí (Áíïóïúóôï÷çìåßá x 40)

ôïõ áñéèìïý ôùí ðõñçíïêéíçóéþí�. Ìå âÜóç ôá ðñïç-ãïýìåíá ôÝèçêå ç äéÜãíùóç: �ÐíåõìïíéêÞ ìåôÜóôáóçôïõ áíáöåñïìÝíïõ áðü ôï éóôïñéêü ÷åéñïõñãçèÝíôïòðáñáãáããëéþìáôïò êáé ìéêñÞ ðåñéï÷Þ ðëáêþäïõò ìå-ôáðëáóßáò êáé in situ êáñêéíþìáôïò óôï âñïã÷éêü âëåí-íïãüíï óýóôïé÷á ðñïò ôïí üãêï�.

Ï áóèåíÞò Ýîé ìÞíåò ìåôÜ ôçí åðÝìâáóç âñßóêåôáéóå ðïëý êáëÞ êáôÜóôáóç ìå ïäçãßåò ãéá áíá Ýôïò ðáñá-êïëïýèçóç ìå õðïëïãéóôéêÞ ôïìïãñáößá èþñáêïò.

ÓÕÆHÔÇÓÇ

ÐáñïõóéÜæïõìå ðåñßðôùóç ìåôáóôáôéêïý ðáñáãáã-ãëéþìáôïò óôïí ðíåýìïíá ëüãù ôçò óðáíéüôçôïò áõôïýôïõ üãêïõ åßôå áöïñÜ óå äåõôåñïðáèÞ åßôå óå ðñùôï-ðáèÞ åíôüðéóç óôïí ðíåýìïíá. Åðßóçò åíäéáöÝñïí ðá-ñïõóéÜæåé ç ôáõôü÷ñïíç áíÜðôõîç in situ âñïã÷ïãåíïýòêáñêéíþìáôïò áðü ðëáêþäåò åðéèÞëéï óôï ßäéï óçìåßïìå ôçí åíôüðéóç ôïõ ìåôáóôáôéêïý üãêïõ.

Ôá ðáñáãÜããëéá áðïôåëïýí ïõóéáóôéêÜ ìÝñïò ôïõíåõñïåíäïêñéíéêïý óõóôÞìáôïò áöïý åêêñßíïõí ìéáðïéêéëßá ïñìïíþí êáé ñõèìéóôéêþí íåõñïðåðôéäßùí. ÓåáõôÜ áíÞêïõí êáé ôá êáñùôéäéêÜ óùìÜôéá ðïõ áðïôå-ëïýí êáé ôçí ðñþôç ðåñéãñáöÞ ðáñáãáããëéáêïý éóôïý1.Ôá åîùåðéíåöñéäéáêÜ ðáñáãÜããëéá å÷ïõí ìéá åõñåßáêáôáíïìÞ ðïõ áêïëïõèåß áõôÞí ôïõ óõìðáèçôéêïý íåõ-ñéêïý óõóôÞìáôïò êáé åêôåßíïíôáé áðü ôçí êåöáëÞ-ôñÜ-÷çëï, Ýùò ôïí èþñáêá êáé ôçí êïéëéÜ. Ôá ðáñáãáããëéþ-ìáôá óõíéóôïýí üãêïõò áõôïý ôïõ óõóôÞìáôïò ìå óõ-

÷íüôåñç åíôüðéóç óôïí ïðéóèïðåñéôïíáúêü ÷þñï, ïðïõ-äÞðïôå áðü ôçí Üíù êïéëßá Ýùò ôçí ðýåëï2. Ç åíäïðíåõ-ìïíéêÞ åíôüðéóç áöïñÜ óå ðïóïóôü ðåñßðïõ 12%3. Óôçâéâëéïãñáößá å÷ïõí ÷ñçóéìïðïéçèåß êáôÜ êáéñïýò äéÜ-öïñïé üñïé ãéá íá ðåñéãñÜøïõí áõôïýò ôïõò üãêïõòüðùò: üãêïé êáñùôéäéêïý óùìáôßïõ, glomus tumors,chemodectomas ê.á.1

Ïé üãêïé áõôïß èåùñïýíôáé ëåéôïõñãéêïß üôáí åêêñß-íïõí êáôå÷ïëáìßíåò, åýñçìá áóýíçèåò ãéá ôá åîùåðé-íåöñéäéáêÜ ðáñáãáããëéþìáôá. Åßíáé óõíÞèùò ïìáëïßüãêïé ìå äéÜìåôñï áðü ëßãá åêáôïóôÜ Ýùò êáé 20 åêá-ôïóôÜ4. Áí êáé èåùñïýíôáé êáôÜ âÜóç êáëïÞèåéò üãêïé,ðåñéðôþóåéò êáêïÞèåéáò Ý÷ïõí áíáöåñèåß óå ïðïéïäÞ-ðïôå óçìåßï êáé áí åíôïðßæïíôáé. Ôï ðéï éó÷õñü êñéôÞ-ñéï ãéá ôç äéÜãíùóç êáêïÞèåéáò åßíáé ç ìåôÜóôáóç áðï-äåäåéãìÝíç ìå âéïøßá êáé ç áíåýñåóç ðáñáãáããëéáêïýéóôïý óå èÝóç üðïõ öõóéïëïãéêÜ áõôüò äåí õößóôáôáé5,6.

ÄéáãíùóôéêÜ ç õðïëïãéóôéêÞ ôïìïãñáößá âïçèÜóôçí ðñïåã÷åéñçôéêÞ åêôßìçóç ãéá ôçí Ýêôáóç ôïõ üãêïõ,ôçí ðñïóâïëÞ ïóôþí êáé ôç óõíïäü ëåìöáäåíïðÜèåéá.Ç ìáãíçôéêÞ ôïìïãñáößá äßíåé êõñßùò óôïé÷åßá ãéá äéÞ-èçóç óôç âÜóç ôïõ êñáíßïõ Þ ãéá äéÞèçóç áããåßùí7.

Äåí õðÜñ÷ïõí óáöåßò áíáöïñÝò ãéá áíåýñåóç ðá-ñáãáããëßùí óôïí ðíåýìïíá êáé åßíáé äýóêïëç ç åíôüðé-óÞ ôïõò óå áíèñþðïõò8. Ðáñ�üëá áõôÜ õðÜñ÷ïõí ìåìï-íùìÝíåò áíáöïñÝò ãéá ðñùôïðáèÞ ðáñáãáããëéþìáôáðíåýìïíá9-13.

Ïé ðåñéðôþóåéò ìåôáóôáôéêþí ðáñáãáããëéùìÜôùí


éäñþôåò, áßóèçìá ðáëìþí, õðåñôáóéêÝò êñßóåéò). Áí êáéóõíÞèùò, üðùò ðñïáíáöÝñèçêå, ôá åîùåðéíåöñéäéáêÜðáñáãáããëéþìáôá äåí åßíáé ëåéôïõñãéêÜ, åí ôïýôïéòõðÜñ÷ïõí áíáöïñÝò ãéá ëåéôïõñãéêÝò ìåôáóôÜóåéò ôùíüãêùí áõôþí ìå åíôüðéóç óå ïóôÜ êáé ðíåýìïíåò16.

Ç èåñáðåßá ôùí ðáñáãáããëéùìÜôùí óôçñßæåôáé êáôÜâÜóç óôç ÷åéñïõñãéêÞ åîáßñåóç ôïõ ðñùôïðáèïýòüãêïõ, åíþ áíÜëïãç óôñáôçãéêÞ áêïëïõèåßôáé êáé ãéáôéò ìåôáóôáôéêÝò åóôßåò17. Ç áêôéíïèåñáðåßá ðåñéïñßæå-ôáé êõñßùò óå ðáñáãáããëéþìáôá êåöáëÞò êáé ôñá÷Þ-ëïõ18 êáé ç ðñüãíùóç åßíáé êáëÞ, åéäéêÜ ìåôÜ áðü ÷åé-ñïõñãéêÞ áöáßñåóç, êáèþò ôá ðáñáãáããëéþìáôá èåù-ñïýíôáé üãêïé ìå áñãÞ åîÝëéîç19,20.

ðíåýìïíá åßíáé åðßóçò åëÜ÷éóôåò üðùò öáßíåôáé áðü ôçäéåèíÞ âéâëéïãñáößá. ÁíáöÝñåôáé ðåñßðôùóç ðïëëá-ðëþí ðíåõìïíéêþí ìåôáóôÜóåùí åðôÜ ÷ñüíéá ìåôÜ áðüåìâïëéóìü êáé áêôéíïèåñáðåßá ðáñáãáããëéþìáôïò ôïõáõ÷Ýíá14. ÁíáöÝñåôáé åðßóçò ðåñßðôùóç ÷åéñïõñãéêÞòáöáßñåóçò ìåôáóôáôéêïý ðáñáãáããëéþìáôïò ðíåýìïíáìå åê íÝïõ õðïôñïðÞ êáé íÝá ÷åéñïõñãéêÞ åðÝìâáóç ôñßá÷ñüíéá ìåôÜ15.

Óôï ðåñéóôáôéêü ðïõ ðáñïõóéÜæïõìå, ç ìåôÜóôáóçóçìåéþèçêå Ýîé ÷ñüíéá ìåôÜ ôçí ôåëåõôáßá ÷åéñïõñãéêÞåîáßñåóç ôçò ðñùôïðáèïýò åóôßáò êáé Þôáí ìç ëåéôïõñ-ãéêÞ, êáèþò ï áóèåíÞò äåí åìöÜíéæå óõìðôùìáôïëïãßááõîçìÝíçò ðáñáãùãÞò êáôå÷ïëáìéíþí (êåöáëáëãßá,

SUMMARY

Pulmonary metastatic paraganglioma in association with in situ bronchogenic carcinoma

K. Katsoulis, G. Papachristos, Th. Zaramboukas, Th. Kontakiotis, A. Nalbantis

We present a case of pulmonary metastatic paraganglioma in association with in situ bronchogeniccarcinoma. The primary tumor was located in the retroperitoneum and was surgically excised six yearsago. The metastatic tumor was accidentally found on a chest x-ray and was initially considered as aprimary bronchogenic carcinoma. The patient underwent lobectomy during which a metastaticparaganglioma was diagnosed. Paragangliomas are tumors of the neuroendocrine system, usually locatedin the abdomen. Pulmonary paragangliomas are rarely found. They are considered functioning whenlarge amounts of catecholamines are excreted and they are surgically treated prognosis being satisfactory.Pneumon 2003, 16(1):86-90.

Key words: paraganglioma. neuroendocrine tumors, pulmonary metastases, bronchogenic carcinoma

5. Walsh RM, Leen EJ, Gleeson MJ et al. Malignant vagalparaganglioma. J Laryngol Otol 1997;111:83-88.

6. Heinrich MC, Harris AE, Bell WR. Metastatic intrava-gal paraganglioma: case report and review of the litera-ture. Am J Med 1985;78:1017-1024.

7. Van Cills APG, van der Mey AGL, Hoogma RDLM, etal: MRI screening of kindred at risk developing paragan-gliomas: support for genomic imprinting in hereditaryglomus tumors. Br J Cancer 1992;65:903-907.

8. Lack EE. Pathology of adrenal and extra-adrenalparaganglia. Major problems in pathology. Vol 29. WBSaunders, Philadelphia, 1994.

9. Goodman ML, Laforet EG. Solitary primary chemodec-tomas of the lung. Chest 1072;61:48-50.

10. Lee YN, Hori JM. Chemodectoma of the lung. J SurgOncol 1972;4:33-36.


1. Ernest Lack, Paragangliomas, In Sternberg S. Diagnos-tic Surgical Pathology, 3rd edition, Lippicontt Williams& Wilkins, Philadelphia, 1999; p625-648.

2. Lack EE. Tumors of the adrenal gland and extra-adre-nal paraganglia. In: Atlas of tumor pathology, 3rd series,fascile 19, Washington DC: Armed Forces Institute ofPathology, 1997.

3. Fries JG, Chamberlin JA. Extra-adrenal pheochromocy-toma: literature review and report of a cervical pheo-chromocytoma. Surgery 1968;63:268-279.

4. Lack EE, Cubilla AL, Woodruff JM, Lieberman PH.Extraadrenal paragangliomas of the retroperitoneum: aclinicopathologic study of 12 tumors. Am J Surg Pathol1980;4:109-120.


11. Corrin B. Unusual tumours and tumour-like conditionsof the lung. Curr Diagn Pathol 1996;3:1-13.

12. Gaertner EM, Steiberg DM, et al. Pulmonary and medi-astinal glomus tumors-report of five cases including apulmonary glomangiosarcoma: a clinicopathologic studywith literature review. Am J Pathol 2000;24(8):1105-14.

13. Lemonick DM, Pai PB, Hines GL. Malignant primarypulmonary paraganglioma with hilar metastasis. J Tho-rac Cardiovasc Surg 1990; 99(3):563-4.

14. Tan KL, Math PK, Rajarooya C, Sim CS, Chia FK.Paraganglioma with pulmonary metastases: a case report.Ann Acad Med Singapore1996; 25(4):592-5.

15. Sato N. Recurrence and pulmonary metastasis of extra-dural paraganglioma in thoracic vertebral canal:reportof a case. Japanese Journal of Thorac Surg 2001;54(7):610-3.

16. Fernandez-Llamarazares J, et al. Functioning metastas-es of a nonfunctioning paraganglioma. J Surg Oncol 1988;37(3):213-4.

17. Sclafani LM, Woodruff JM, Brennan MF. Extraadrenalretroperitoneal paragangliomas: natural history and re-sponse to treatment. Surgery 1990; 108:1124-1130.

18. Lybeert ML, van Andel JG, Eijkenboon WM, et al: ra-diotherapy of paragangliomas. Clin Otolaryngol 1984;9:150-159.

19. Van den Broek PJ, de Graeff J. Prolonged survival in apatient with pulmonary metastases of a malignantpheocromocytoma. Neth L Med 1978; 21(6):245-7.

20. Vuorela AL, Jakobson M, Anttinen J. Slowly growingpulmonary metastases of malignant cervical chemodec-toma. Acta Oncol 1994; 33(1):77-8.

Ðåñßðôùóç áðïöñáêôéêÞò âñïã÷éïëßôéäáòìå ïñãáíïýìåíç ðíåõìïíßá ìéìïýìåíç êáñêßíïôïõ ðíåýìïíïò

Áëëçëïãñáößá:Äñ Êùí/íïò ÐüôáñçòÔìÞìá ×åéñïõñãéêÞò ÈþñáêïòÃåíéêü Íïóïêïìåßï ÁôôéêÞò �ÊÁÔ�Íßêçò 2, ÊçöéóéÜ 145 61Ôçë.: +210-6280285Fax: +210-6012587E-mail: [email protected]

ÐÅÑÉËÇØÇ. ¢íäñáò 48 åôþí, êáðíéóôÞò, åéóÞ÷èç óôçí êëéíéêÞìáò ëüãù áéìüðôõóçò, áäõíáìßáò, êáôáâïëÞò êáé áíïñåîßáò áðü20çìÝñïõ. Óôïí áêôéíïëïãéêü Ýëåã÷ï äéáðéóôþèçêå ìÜæá ìáëá-êþí ìïñßùí äéáìÝôñïõ 3 åê. óôïí äåîéü êÜôù ëïâü ôïõ ðíåýìïíïò,êåíôñéêÜ åíôïðéóìÝíç. Ï õðüëïéðïò êëéíéêüò êáé åñãáóôçñéáêüòôïõ Ýëåã÷ïò äåí áíÝäåéîå Üëëá ðáèïëïãéêÜ åõñÞìáôá. Ç âñïã÷ï-óêüðçóç, ç êõôôáñïëïãéêÞ åîÝôáóç êáé ç êáëëéÝñãåéá ôùí âñïã-÷éêþí åêêñßóåùí äåí Þôáí äéáãíùóôéêÝò. Ìå ôçí áêôéíïëïãéêÞ êáéìüíï õðïøßá êáñêßíïõ ôïõ ðíåýìïíïò ï áóèåíÞò õðïâëÞèçêå óåäåîéÜ èùñáêïôïìÞ. Óôçí ôá÷åßá âéïøßá ôïõ üæïõ ôÝèçêå ç õðï-øßá êáêïÞèåéáò êáé áêïëïýèçóå äåîéÜ êÜôù ëïâåêôïìÞ ìå ñéæéêüëåìöáäåíéêü êáèáñéóìü ôïõ ìåóïèùñáêßïõ. Óôéò ìüíéìåò üìùòéóôïëïãéêÝò ôïìÝò áðïäåß÷èçêå üôé åðñüêåéôï ãéá áðïöñáêôéêÞâñïã÷éïëßôéäá ìå ïñãáíïýìåíç ðíåõìïíßá. Óôïí áóèåíÞ äåí ÷ï-ñçãÞèçêå êïñôéæüíç ìåôåã÷åéñçôéêÜ êáé äþäåêá ìÞíåò ìåôÜ äåíÝ÷åé äéáðéóôùèåß êëéíéêÞ Þ áêôéíïëïãéêÞ õðïôñïðÞ ôçò ðÜèçóçò.Ç åíäéáöÝñïõóá áõôÞ ðåñßðôùóç êáôáäåéêíýåé üôé ü÷é ìüíï çêëéíéêÞ Þ ç áêôéíïëïãéêÞ åéêüíá ôçò áðïöñáêôéêÞò âñïã÷éïëßôé-äáò ìå ïñãáíïýìåíç ðíåõìïíßá áëëÜ êáé ç ôá÷åßá âéïøßá ìðï-ñïýí íá ðáñáðëáíÞóïõí ãéá íåïðëáóßá ôïõ ðíåýìïíïò. Ðíåýìùí2003, 16(1):91-96.

ÅÉÓÁÃÙÃH

Ç ðñþôç êëéíéêÞ êáé ðáèïëïãïáíáôïìéêÞ ðåñéãñáöÞ ôçò áðïöñáêôé-êÞò âñïã÷éïëßôéäáò ìå ïñãáíïýìåíç ðíåõìïíßá (Bronchiolitis ObliteransOrganizing Pneumonia - BOOP), Ýãéíå ôï 1985 áðü ôïí Epler1. Ç éóôïëï-ãéêÞ ôçò åéêüíá ÷áñáêôçñßæåôáé áðü ôçí áíÜðôõîç êïêêéþäïõò éóôïý óôïíáõëü ôùí ìéêñþí áåñáãùãþí ðïõ åðåêôåßíåôáé ðåñéöåñéêÜ óôïõò êõøå-ëéäéêïýò ðüñïõò êáé óôéò êõøåëßäåò üðïõ ìðïñåß íá óõíõðÜñ÷åé óõóóþ-

K. Ðüôáñçò1,Ð. Ìß÷ïò1,É. Ãáêßäçò1,Å. Ìá÷áßñá2

1ÔìÞìá ×åéñïõñãéêÞò Èþñáêïò, 2ÅñãáóôÞñéï Ðáèï-ëïãéêÞò ÁíáôïìéêÞò Ãåíéêü Íïóïêïìåßï ÁôôéêÞò,"ÊÁÔ"

ËÝîåéò - êëåéäéÜ: áðïöñáêôéêÞ âñïã÷éïëßôéäá ìåïñãáíïýìåíç ðíåõìïíßá, øåõäïïãêüìïñöç ìïñ-öÞ



ñåõóç áðü áöñþäç ìáêñïöÜãá. ÊëéíéêÜ ç ðëåéïíüôç-ôá ôùí áóèåíþí ðáñïõóéÜæåé îçñü âÞ÷á, ÷áìçëÞ ðõñå-ôéêÞ êßíçóç êáé ðñïïäåõôéêÞ äýóðíïéá. Áìöïôåñüðëåõ-ñåò Þ åôåñüðëåõñåò ðíåõìïíéêÝò äéçèÞóåéò óôá ìÝóá êáéêÜôù ðíåõìïíéêÜ ðåäßá åßíáé ôï óõ÷íüôåñï åýñçìá óôçíáêôéíïãñáößá èþñáêïò. Ëéãüôåñï óõ÷íÜ ðåñéãñÜöåôáéç ðáñïõóßá ìïíÞñïõò Þ ðïëëáðëþí ðíåõìïíéêþí ïæé-äßùí ìå Þ ÷ùñßò óðçëáéïðïßçóç. Ðïëý óðÜíéá Ý÷åé ðá-ñáôçñçèåß äéüãêùóç åðé÷ùñßùí ëåìöáäÝíùí êáé ôÝëïòÝ÷åé áíáöåñèåß êáé óõíýðáñîç õäñïðíåõìïèþñáêá ìåìïíÞñåò ðíåõìïíéêü ïæßäéï. Ç äéÜãíùóç ãßíåôáé óõíÞ-èùò ìå ðáñáêÝíôçóç ìå ëåðôÞ âåëüíá (Fine NeedleAspiration Cytology - FNAC) äéáèùñáêéêÜ õðü áîïíé-êü ôïìïãñÜöï Þ äéáâñïã÷éêÜ êáôÜ ôç äéÜñêåéá âñïã-÷ïóêüðçóçò. Ç éóôïëïãéêÞ åîÝôáóç üìùò ìåôÜ áðü áíïé-êôÞ âéïøßá ðíåýìïíïò èÝôåé óßãïõñá ôç äéÜãíùóç2-4.

Óôç ðáñïýóá åñãáóßá ðáñïõóéÜæåôáé ìéá åíäéáöÝ-ñïõóá ðåñßðôùóç øåõäïïãêüìïñöçò åîåñãáóßáò ðíåý-ìïíïò, ïöåéëüìåíç óå BOOP, ìå ýðïðôç ãéá êáêïÞèåéá,ôá÷åßá âéïøßá.

ÐåñéãñáöÞ ðåñßðôùóçò

Ðñüêåéôáé ãéá Üíäñá áóèåíÞ 48 åôþí, ïéêïíïìéêüìåôáíÜóôç áðü ôçí Áëâáíßá, âáñý êáðíéóôÞ (3 ðáêÝôáóéãáñÝôá ôçí çìÝñá ãéá ôñéÜíôá ÷ñüíéá), ðïõ ðñïóÞëèå

óôï ÔìÞìá Åðåéãüíôùí ôïõ íïóïêïìåßïõ ìáò ãéá èùñá-êï÷åéñïõñãéêÞ åêôßìçóç. Ôéò ôåëåõôáßåò 20 çìÝñåò ðá-ñïõóßáæå áéìüöõñôá ðôýåëá êáé áíÝöåñå áéìüðôõóç 20ê.åê. ðåñßðïõ, ðáñáôçñçèåßóá ôñåéò öïñÝò, áäõíáìßá,êáôáâïëÞ êáé áíïñåîßá. Äåí áíÝöåñå áëëáãÞ ÷ñïéÜò ôïõ÷ñüíéïõ �ùò âáñý êáðíéóôÞ- âÞ÷á, äýóðíïéá, èùñáêé-êü Üëãïò, ðõñåôü Þ áðþëåéá âÜñïõò. Óôï áôïìéêü ôïõáíáìíçóôéêü áíáöÝñåôáé ìüíï Ýíá åðåéóüäéï áõôüìá-ôïõ ðíåõìïèþñáêá áñéóôåñÜ, ðñéí áðü 15 Ýôç, ðïõ áíôé-ìåôùðßóôçêå ìå óùëÞíá êëåéóôÞò ðáñï÷Ýôåõóçò èþñá-êïò óôçí ðáôñßäá ôïõ. Ç êëéíéêÞ åîÝôáóç ôïõ èþñáêïò,åêôüò áðü Ýíá ôñá÷ý áíáðíåõóôéêü øéèýñéóìá ëüãùåêêñßóåùí, äåí åß÷å Üëëá åõñÞìáôá. Åðßóçò áñíçôéêÞÞôáí ç åîÝôáóç ôçò êïéëéÜò, ôçò êåöáëÞò, ôïõ äÝñìáôïò,üðùò êáé ôïõ ìõïóêåëåôéêïý êáé êõêëïöïñéêïý óõóôÞ-ìáôïò. Ôá æùôéêÜ ôïõ óçìåßá Þôáí åíôüò öõóéïëïãéêþíïñßùí êáé óôá áÝñéá áßìáôïò åß÷å PaO2 72 mmHg êáéPCO2 36 mmHg. Óôç óðéñïìÝôñçóç âñÝèçêå FEV1 2.4L êáé FVC 3.2 L. Ï áéìáôïêñßôçò Þôáí 43%, ôá ëåõêÜáéìïóöáßñéá 6270 êê÷ (ðïëõìïñöïðýñçíá 49%, ëåìöï-êýôôáñá 35%, ìïíïêýôôáñá 9%, çùóéíüöéëá 5%, âá-óåüöéëá 1%). Ç ÔÊÅ Þôáí 45 ôçí ðñþôç þñá êáé ïé âéï-÷çìéêÝò ôïõ åîåôÜóåéò åíôüò ôùí öõóéïëïãéêþí ïñßùí.Äåí åóôÜëç êïëëáãïíéêüò Þ éïëïãéêüò Ýëåã÷ïò, ïýôåASTO Þ CRP. Ç åîÝôáóç Mantoux áðÝâç áñíçôéêÞ

Åéêüíá 1. Ïðéóèïðñüóèéá êáé ðëÜãéá áêôéíïãñáößá èþñáêïò áóèåíïýò ìå ÷ùñïêáôáêôçôéêÞ åîåñãáóßá ôïõ äåîéïý êÜôù ëïâïýðíåýìïíïò, ïöåéëüìåíç óå BOOP.


üðùò êáé ïé êáëëéÝñãåéåò ðôõÝëùí ãéá âÜêéëëï ôïõ KochÞ Üëëá ìéêñüâéá. Óôçí áêôéíïãñáößá èþñáêïò, üðùòöáßíåôáé óôçí Åéêüíá 1, äéáðéóôþèçêå Ýíáò êåíôñéêÜåíôïðéæüìåíïò ðíåõìïíéêüò üæïò óôï äåîéü Ýóù êáé êÜôùðíåõìïíéêü ðåäßï, äéáìÝôñïõ ðåñßðïõ 3 åê., ìå ó÷åôéêÜïìáëü ðåñßãñáììá êáé ÷ùñßò áðïôéôáíþóåéò. Óôçí áîï-íéêÞ ôïìïãñáößá èþñáêïò, üðùò öáßíåôáé óôçí Åéêüíá2, äéáðéóôþèçêå ìÜæá ìå ðõêíüôçôá ìáëáêþí ìïñßùíóôï Ýóù âáóéêü ôìÞìá ôïõ äåîéïý êÜôù ëïâïý ìå ôïõòðáñáðÜíù ÷áñáêôÞñåò êáé äéÜ÷õôåò áëëïéþóåéò áðï-öñáêôéêÞò ðíåõìïíïðÜèåéáò ÷ùñßò äéüãêùóç ëåìöáäÝ-íùí ìåóïèùñáêßïõ Þ Üëëá åõñÞìáôá. Óôç âñïã÷ïóêü-ðçóç äéáðéóôþèçêå åñõèñüôçôá ôïõ Ýóù âáóéêïý ôìç-ìáôéêïý âñüã÷ïõ ôïõ äåîéïý êÜôù ëïâïý ìå áñíçôéêübrushing êáé êõôôáñïëïãéêÞ. Ïé êáëëéÝñãåéåò ôùí âñïã-÷éêþí åêêñßóåùí áðÝâçóáí óôåßñåò. Ëüãù ôçò åíôüðé-óçò ôïõ üæïõ äåí óõæçôÞèçêå ôï åíäå÷üìåíï ðáñáêÝ-íôçóÞò ôïõ õðü áîïíéêü ôïìïãñÜöï. Ï áóèåíÞò õðï-âëÞèçêå óå äåîéÜ åñåõíçôéêÞ èùñáêïôïìÞ ìå ôçí õðï-øßá íåïðëáóßáò ôïõ ðíåýìïíïò áöïý ðñïçãÞèçêå óôá-äéïðïßçóç êáé ï Ýëåã÷ïò ãéá ôõ÷üí äåõôåñïðáèåßò åíôï-ðßóåéò áðÝâç áñíçôéêüò. ̧ ãéíå óöçíïåéäÞò åêôïìÞ ôïõüãêïõ, åðß õãéïýò ðíåõìïíéêïý ðáñåã÷ýìáôïò, ìå ôç÷ñÞóç áõôüìáôùí óõññáðôéêþí åñãáëåßùí êáé áõôÞåóôÜëç ãéá ôá÷åßá âéïøßá. Ëüãù ôçò áíåýñåóçò Üôõðùí,ðéèáíþò áíôéäñáóôéêþí ðíåõìïíïêõôôÜñùí, óå óõíäõá-

óìü ìå åêóåóçìáóìÝíç ßíùóç, ç ôá÷åßá âéïøßá äüèçêåýðïðôç ãéá êáêïÞèåéá. Ùò åê ôïýôïõ äéåíåñãÞèçêå äå-îéÜ êÜôù ëïâåêôïìÞ ìå ñéæéêü ëåìöáäåíéêü êáèáñéóìüôïõ ìåóïèùñáêßïõ. Ç ìåôåã÷åéñçôéêÞ ðïñåßá ôïõ áóèå-íïýò Þôáí ó÷åôéêÜ ïìáëÞ ÷áñáêôçñéæüìåíç áðü ôçí áíå-ðáñêÞ Ýêðôõîç ôïõ äåîéïý ìÝóïõ êáé Üíù ëïâïý, ÷ùñßòäéáöõãÞ áÝñá, ìå áðïôÝëåóìá ôçí äçìéïõñãßá �÷þñïõ´óôç êïñõöÞ ôïõ äåîéïý çìéèùñáêßïõ. Ç éóôïëïãéêÞ åîÝ-ôáóç Ýäåéîå óå áðüóôáóç 2 åê. áðü ôï êïëüâùìá ôïõâñüã÷ïõ ïãêüìïñöç åîåñãáóßá ìå êõóôéêÝò äéáôÜóåéò,ðïõ ðëçñïýíôáé áðü áéìïññáãéêü êáé åí ìÝñåé æåëáôé-íþäåò ðåñéå÷üìåíï. Óôéò ôïìÝò ðïõ åîåôÜóôçêáí óôïáðëü ìéêñïóêüðéï, ìå ÷ñþóç áéìáôïîõëßíçò - çùóßíçò,ðáñáôçñÞèçêå áíÜðôõîç éíþäïõò óõíäåôéêïý éóôïý ìå-ôáîý ôùí êõøåëßäùí êáé ðõêíÜ öëåãìïíþäç óôïé÷åßááðïôåëïýìåíá áðü ëåìöïêýôôáñá êáé ìáêñïöÜãá, åõ-ñÞìáôá óõìâáôÜ ìå åóôéáêÞ ïñãáíïýìåíç ðíåõìïíßá ôïõôýðïõ áðïöñáêôéêÞò âñïã÷éïëßôéäáò (Åéêüíá 3).

Ï áóèåíÞò åîÞëèå ôçí 13ç ìåôåã÷åéñçôéêÞ çìÝñá ëáì-âÜíïíôáò áíôéâßùóç áðü ôïõ óôüìáôïò êáé ìå õðïëåé-ðüìåíç Ýêðôõîç ôïõ ðíåõìïíéêïý ðáñåã÷ýìáôïò äåîéÜ.ÊáôÜ ôçí åðáíåîÝôáóç, ìåôÜ 10 çìÝñåò, äéáðéóôþèçêååêôüò áðü ôçí õðïëåéðüìåíç Ýêðôõîç, ìåãáëýôåñç áôå-ëåêôáóßá ôïõ äåîéïý ìÝóïõ ëïâïý êáé ìéêñÞ ðëåõñéôéêÞóõëëïãÞ. Ï áóèåíÞò õðïâëÞèçêå óå âñïã÷ïóêüðçóçêáôÜ ôçí ïðïßá Ýãéíå áíáññüöçóç ôùí åêêñßóåùí êáé

Åéêüíá 2. ÁîïíéêÞ ôïìïãñáößá èþñáêïò áóèåíïýò ìå ÷ùñïêáôáêôçôéêÞ åîåñãáóßá ôïõ äåîéïý êÜôù ëïâïý ðíåýìïíïò, ïöåéëüìå-íç óå BOOP.


áéôéïëïãßáò ìå ðïëëÝò áíáöïñÝò óôç äéåèíÞ âéâëéïãñá-ößá.

ÐñïóâÜëëåé Üíäñåò êáé ãõíáßêåò åîßóïõ, óõ÷íüôå-ñá óôéò çëéêßåò 40 Ýùò 60 åôþí. Ôï 90% ôùí ðáó÷üíôùíåßíáé ðñþçí Þ óõíå÷ßæïíôåò êáðíéóôÝò. Ôüóï ôï öÜóìáôùí êëéíéêþí üóï êáé ôùí áêôéíïëïãéêþí ôçò åõñçìÜ-ôùí åßíáé ìåãÜëï. ÓõíáíôÜôáé ìå ôñåéò ìïñöÝò êáé óõ-ãêåêñéìÝíá: á) ôçí ïîåßá ìïñöÞ, ðïõ ìðïñåß íá åßíáéêáé áðåéëçôéêÞ ãéá ôç æùÞ ôïõ áóèåíïýò, â) ôçí õðï-îåßá, ðïõ åßíáé ç ðéï óõ÷íÞ ìïñöÞ êáé åêäçëþíåôáé ìåðñïïäåõôéêü ìç ðáñáãùãéêü âÞ÷á, áäéáèåóßá, ðõñåôüêáé áðþëåéá âÜñïõò êáé ã) ôç ÷ñüíéá ðïõ äéáêñßíåôáéóå ðñïïäåõôéêÞ êáé õðïôñïðéÜæïõóá2,5.

ÐïëëÝò ðñùôïðáèåßò äéáôáñá÷Ýò Ý÷ïõí óõó÷åôéóôåßìå ðíåõìïíéêÝò áíôéäñÜóåéò êáé ðáèïëïãïáíáôïìéêÜ÷áñáêôçñéóôéêÜ ôçò BOOP, üðùò áíáðíåõóôéêÝò ëïéìþ-îåéò áðü éïýò êáé âáêôÞñéá, åéóðíïÞ ôïîéêþí ïõóéþí,áíåðéèýìçôåò åíÝñãåéåò öáñìÜêùí êáé ðáèÞóåéò ôïõêïëëáãüíïõ. Óôçí ðëåéïíüôçôá üìùò ôùí ðåñéðôþóåùíêáíÝíáò áéôéïëïãéêüò ðáñÜãïíôáò äåí áíåõñßóêåôáé(éäéïðáèÞò BOOP Þ cryptogenic organizing pneumo-nia)6.

Ç áêôéíïëïãéêÞ ôçò åìöÜíéóç üðùò ðñïáíáöÝñèç-êå ðïéêßëåé. Óõ÷íüôåñá ðáñáôçñïýíôáé ðïëëáðëÝò åóôßåòðíåõìïíßáò äßêçí "åìâáëùìÜôùí", áëëÜ ìðïñåß íá åì-öáíéóôåß êáé ôõðéêÞ åéêüíá ðíåõìïíßáò Þ åéêüíá äéáìÝ-óïõ ôýðïõ äéÜ÷õôçò ðíåõìïíïðÜèåéáò. Ôï ÷áñáêôçñé-óôéêü êáé ôùí ôñéþí áõôþí ìïñöþí åßíáé üôé õðï÷ùñïýíìå ôç ÷ïñÞãçóç êïñôéæüíçò. Ç ìïñöÞ üìùò ðïõ êÜíåéôçí BOOP åíäéáöÝñïõóá äéáöïñïäéáãíùóôéêÜ åßíáéáõôÞ ôïõ ìïíÞñïõò Þ ôùí ðïëëáðëþí ðíåõìïíéêþí ïæé-äßùí, ìå Þ ÷ùñßò óðçëáéïðïßçóç3,4,6. Êáé áõôü äéüôé çÂÏÏP ìå áõôÞ ôç ìïñöÞ ôßèåôáé óôç äéáöïñéêÞ äéÜãíù-óç ôïõ ìïíÞñïõò ðíåõìïíéêïý ïæéäßïõ. Óôç ðåñßðôùóçðïõ ðáñïõóéÜæïõìå, ùò üæïò ôïõ ðíåýìïíá, õðïäõüôáíôçí áêôéíïëïãéêÞ åéêüíá ôïõ êáñêßíïõ ôïõ ðíåýìïíïòÝ÷ïíôáò êåíôñéêÞ åíôüðéóç, äéÜìåôñï Ýùò 3 åê., ðïëõëï-âùôÜ üñéá êáé áõîçìÝíç ðñüóëçøç ôïõ óêéáãñáöéêïý.Åðßóçò óõíïäåõüôáí êëéíéêÜ áðü áéìüðôõóç êáé âñïã-÷ïóêïðéêÜ áðü åñõèñüôçôá ôïõ óôïìßïõ ôïõ êÜôù Ýóùôìçìáôéêïý âñüã÷ïõ. Óå ìéá ìåëÝôç áðü ôç ìåãÜëçÂñåôáíßá, ïé Murphy êáé óõí. áíáöÝñïõí ðÝíôå ðåñé-ðôþóåéò ìïíÞñùí ïæéäßùí, ïöåéëïìÝíùí óå BOOP, ìåêëéíéêÞ êáé áêôéíïëïãéêÞ åéêüíá ìéìïýìåíç âñïã÷ïãå-íÞ êáñêßíï7.

Åéêüíá 3. ÁíÜðôõîç éíþäïõò óõíäåôéêïý éóôïý ìåôáîý êõøå-ëßäùí, ìå ðõêíÜ öëåãìïíþäç óôïé÷åßá áðïôåëïýìåíá áðü ëåì-öïêýôôáñá êáé ìáêñïöÜãá, ïöåéëüìåíç óå BOOP.

Ýêðëõóç ôïõ âñïã÷éêïý äÝíäñïõ. ÅîÞëèå ôçí åðïìÝíçìå âåëôßùóç ôçò áêôéíïëïãéêÞò ôïõ åéêüíáò. Óôçí åðá-íåîÝôáóç, ìåôÜ áðü 12 çìÝñåò, äéáðéóôþèçêå åêñïÞ êé-ôñéíùðïý õãñïý óôçí õðÜñ÷ïõóá ôïìÞ åîüäïõ ôïõ óù-ëÞíá êëåéóôÞò èùñáêéêÞò ðáñï÷Ýôåõóçò, ðïõ üðùò áðï-äåß÷èçêå ïöåéëüôáí óå ôÞîç ëßðïõò, ðáñáìïíÞ ôïõ �÷þ-ñïõ� êáé áôåëåêôáóßá ôïõ äåîéïý ìÝóïõ ëïâïý. Ëüãùôçò åìöÜíéóçò ÷áìçëÞò ðõñåôéêÞò êßíçóçò, Ýùò 37.5ï C,áðü äéçìÝñïõ êáé ôçò áýîçóçò ôùí ëåõêþí áéìïóöáé-ñßùí (10.100 êê÷, 69.5% ðïëõìïñöïðýñçíá), ï áóèå-íÞò ïäçãÞèçêå óôï ÷åéñïõñãåßï ìå ôçí õðïøßá åìðõÞ-ìáôïò èþñáêïò. ÕðïâëÞèçêå óå Video-ássisted Thorac-ic Surgery (VATS), êáôÜ ôçí ïðïßá äåí äéáðéóôþèçêåðýïí Þ øåõäïìåìâñÜíåò åíôüò ôïõ çìéèùñáêßïõ. Áíáñ-ñïöÞèçêå ôï ïñþäåò õãñü, åóôÜëçóáí êáëëéÝñãåéåò,Ýãéíå ìç÷áíéêÞ ðëåõñïäåóßá, êáé ìå ôïí ìç÷áíéêü áåñé-óìü åðáíåêðôý÷èçêå ï äåîéüò ìÝóïò ëïâüò. Ïé êáëëéÝñ-ãåéåò ôïõ õãñïý áðÝâçóáí áñíçôéêÝò. Ï áóèåíÞò åîÞë-èå ôçí 4ç ìåôåã÷åéñçôéêÞ çìÝñá ìå óáöÞ âåëôßùóç ôçòêëéíéêÞò êáé áêôéíïëïãéêÞò ôïõ åéêüíáò, üóïí áöïñÜ ôçíýðáñîç ôïõ �÷þñïõ�. Óôçí åðáíåîÝôáóç, ìåôÜ áðü 6 êáé12 ìÞíåò, ï áóèåíÞò åìöÜíéóå ðëÞñç Ýêðôõîç ôïõ ðíåõ-ìïíéêïý ðáñåã÷ýìáôïò, äåí äéáðéóôþèçêå õðïôñïðÞ ôçòðáèÞóåþò ôïõ êáé Ýíåêá ôïýôïõ äåí ôïõ Ý÷åé ÷ïñçãçèåßáêüìá êïñôéæüíç.

ÓÕÆHÔÇÓÇ

Ç áðïöñáêôéêÞ âñïã÷éïëßôéäá ìå ïñãáíïýìåíçðíåõìïíßá åßíáé ìéá íïóïëïãéêÞ ïíôüôçôá áãíþóôïõ


¼óïí áöïñÜ óôçí ôá÷åßá âéïøßá ôïõ áóèåíïýò ìáò,ïé Crapanzano êáé Zakowski, áðü ôï Memorial SloanKettering Cancer Center, áíáöÝñïõí åðßóçò ìéá ðåñß-ðôùóç ðíåõìïíéêÞò âéïøßáò ìå ëåðôÞ âåëüíç (FNAC)ðïõ áñ÷éêÜ ãíùìáôåýôçêå ùò êáñêéíïåéäÝò, ëüãù ôçòðáñïõóßáò Üôõðùí ðíåõìïíïêõôôÜñùí êáé ç ïðïßá ôå-ëéêÜ áðïäåß÷ôçêå üôé åðñüêåéôï ãéá BOOP8.

Ôï áíôßèåôï Ý÷åé åðßóçò ðåñéãñáöåß, äçëáäÞ, êáñêß-íïò íá åìöáíßæåôáé ìå åéêüíá äéÜìåóïõ ôýðïõ ðíåõìï-íïðÜèåéáò ìéìïýìåíïò BOOP. Óå ìéá ìåëÝôç áðü ôçíÁõóôñáëßá, ìéá ãõíáßêá 38 åôþí ìå éóôïñéêü êáñêßíïõìáóôïý Ýëáâå êïñôéæüíç äéüôé åìöÜíéóå êëéíéêÞ êáé áêôé-íïëïãéêÞ åéêüíá ðïõ èåùñÞèçêå BOOP êáé äåí êñßèç-êå áíáãêáßá ç ëÞøç éóôïëïãéêÞò åîÝôáóçò. ¼ôáí üìùòðáñáôçñÞèçêå üôé äåí õðÞñîå áíôáðüêñéóç, ç áóèåíÞò

õðïâëÞèçêå óå âéïøßá ðíåýìïíïò, ðïõ Ýäåéîå üôé åðñü-êåéôï ãéá ëåìöáããåéáêÞ êáé ðåñéâñïã÷éêÞ äéÞèçóç áðüêáñêßíï ôïõ ìáóôïý9.

Ëüãù ôçò éêáíüôçôáò ôçò BOOP íá ìéìåßôáé ôçí áêôé-íïëïãéêÞ åéêüíá ü÷é ìüíï áñêåôþí öëåãìïíùäþí ðá-èÞóåùí áëëÜ êáé ôïõ âñïã÷ïãåíÞ êáñêßíïõ, ìå âÜóç ôáäéåèíÞ âéâëéïãñáöéêÜ äåäïìÝíá, ðñÝðåé íá åéóÜãåôáéóôç äéáöïñéêÞ äéÜãíùóç ðíåõìïíéêþí ðáèÞóåùí üðùò:áíáðíåõóôéêþí ëïéìþîåùí ÷ùñßò áíåýñåóç ôïõ áéôéï-ëïãéêïý ðáñÜãïíôá, ðíåõìïíéêþí äéçèÞóåùí áãíþóôïõáéôéïëïãßáò, ìïíÞñïõò ðíåõìïíéêïý ïæéäßïõ êáé ðñùôï-ðáèïýò ðíåõìïíéêïý Þ ìåôáóôáôéêïý êáñêßíïõ. ÔÝëïò,ç áíïéêôÞ âéïøßá ôïõ ðíåýìïíïò åßíáé åêåßíç ðïõ èÝôåéìå áóöÜëåéá ôç äéÜãíùóç.

SUMMARY

Á case of bronchiolitis obliterans organizing pneumonia mimicking bronchogenic carcinoma

K. Potaris, P. Michos, J. Gakidis, E. Machera

A 48-year-old man was admitted with hemoptysis, malaise, fatigue and anorexia in the last twentydays. A centrally located, 3 cm soft tissue mass in the right lower lobe of the lung was discovered onradiologic evaluation. His clinical and laboratory evaluation was unrevealing. Bronchoscopy, bronchialcultures and brushing were all negative. He underwent right thoracotomy with the radiologic suspicionof lung cancer. The frozen section was implying malignancy and the patient underwent a right lowerlobectomy with mediastinal lymph node dissection. However, the routine histologic report showedbronchiolitis obliterans organizing pneumonia. Corticosteroids were not given and there is no clinicalor roentgenographic evidence of recurrence of the disease twelve months postoperatively. This interestingcase demonstrates that not only clinical or roentgenographic findings of bronchiolitis obliteransorganizing pneumonia but frozen section too, can be confused with those of lung cancer. Pneumon2003, 16(1):91-96.

Key words: Bronchiolitis obliterans organizing pneumonia, pseudotumor

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Documents

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