Clinical recommendations for treatment of localized angiosarcoma: A consensus paper by the Italian Sarcoma Group

Angiosarcoma (AS) represents a rare and aggressive vascular sarcoma, posing distinct challenges in clinical management compared to other sarcomas. While the current European Society of Medical Oncology (ESMO) clinical practice guidelines for sarcoma treatment are applicable to AS, its unique aggressiveness and diverse tumor presentations necessitate dedicated and detailed clinical recommendations, which are currently lacking. Notably, considerations regarding surgical extent, radiation therapy (RT), and neoadjuvant/adjuvant chemotherapy vary significantly in localized disease, depending on each different site of onset. Indeed, AS are one of the sarcoma types most sensitive to cytotoxic chemotherapy. Despite this, uncertainties persist regarding optimal management across different clinical presentations, highlighting the need for further investigation through clinical trials. The Italian Sarcoma Group (ISG) organized a consensus meeting on April 1st, 2023, in Castel San Pietro, Italy, bringing together Italian sarcoma experts from several disciplines and patient representatives from "Sofia nel Cuore Onlus" and the ISG patient advocacy working group. The objective was to develop specific clinical recommendations for managing localized AS within the existing framework of sarcoma clinical practice guidelines, accounting for potential practice variations among ISG institutions. The aim was to try to standardize and harmonize clinical practices, or at least highlight the open questions in the local management of the disease, to define the best evidence-based practice for the optimal approach of localized AS and generate the recommendations presented herein.

[Italian Registry of Dialysis and Transplantation: 1996-2001 experience]

The Italian Registry of Dialysis and Transplantation (RIDT) was born in 1996 under the aegis of the Italian Society of Nephrology, and it is organized as a federation of regional registries. This study aimed to completely revise the epidemiological data collected during the first 5 yrs (1996-2001) of RIDT activity to evaluate the trends of the main epidemiological features. During this period, regional registries were not always able to assure complete and exhaustive information according to RIDT requirements, owing to different levels of organization and functioning. To avoid any possible error in data analysis, information inadequately assessed was refused. The incidence of end-stage renal disease (ESRD) patients on renal replacement therapy (RRT) in Italy has increased from 114 pmp in 1996 to 139 pmp in 2001, that means an increase of 3.5%/yr, corresponding to 5718 patients during 1996 and 8000 patients during 2001. Primary renal diseases (according to the EDTA) in incident ESRD patients are vascular and diabetic nephropathy. Main dialysis modality in incident patients was hemodialysis (HD) (85%), while peritoneal dialysis (PD) was only 15%; pre-emptive transplantation was a very unusual modality. The prevalence of ESRD patients at 31 December was 693 pmp in 1996 and 827 pmp in 2001; among dialysis patients, the corresponding rates were 575 pmp and 657 pmp, respectively. Consequently, the number of dialyzed patients increased, respectively, from 28892 to 37919. The prevalent dialysis modality was bicarbonate dialysis in 74% of cases, followed by hemodiafiltration (HDF) in 15%, continuous ambulatory peritoneal dialysis (CAPD) in 7% and APD in 3%. The gross mortality rate in dialyzed patients was stable during this period, at approximately 14%, the main causes of death being cardiovascular diseases and cachexia.

Day-to-day variability of adequacy indexes in peritoneal dialysis

BACKGROUND

The achievement of dialysis adequacy targets in peritoneal dialysis (PD) is assessed by the calculation of the Kt/V and creatinine clearance (C(Cr)) obtained by collecting dialysate and urine, usually two or three times a year. Prescription decisions are based on such adequacy assessments, regardless of any variability in the single measurements. The aim of our study was to assess the day-to-day variability of common dialysis adequacy parameters and to evaluate its impact on the adequacy indexes in PD.

METHODS

Twenty-four patients (14 CAPD, 10 APD) at two centres were studied by means of a triple dialysate and urine collection for a period of 1 week. Variability in the findings for a given patient was expressed by the coefficient of variation (CV%) calculated for peritoneal (p), renal, and total (tot) adequacy parameters. The target Kt/V and C(Cr) values were recalculated on the basis of variability.

RESULTS

Kt/V was less variable (CV 4.0 and 4.4% for peritoneal Kt/V (pKt/V) and total Kt/V (totKt/V) respectively) than C(Cr) (4.7 and 6.0% for peritoneal creatinine clearance (pC(Cr)) and total creatinine clearance (totC(Cr)) respectively) and proved to be a more reliable indicator of adequacy in terms of the CV. Both variability parameters became worse if renal clearance was added to peritoneal clearance. CV in APD proved to be no different from CAPD for all the parameters considered. In our centres dialysis adequacy target correction for variability provided safe values for weekly Kt/V (pKt/V=1.78-2.10 and totKt/V=1.82-2.15 target 1.7-2.0) and C(Cr)/1.73 (pC(Cr)=53.7-64.4 l and totC(Cr)=55.1-66.1 l; target 50-60 l).

CONCLUSIONS

Evaluating the adequacy of PD by means of a single measurement should take into account the weekly variability as demonstrated by a triple dialysate and urine collection. Standard adequacy targets can be corrected to allow for variability. Thus one can obtain safe values for prescription decisions based on a single collection result.

Symptoms in hemodialysis patients and their relationship with biochemical and demographic parameters

Symptoms can markedly influence the hemodialysis patients well-being and quality of life. The aim of this paper is to study the frequency of symptoms at home and how these relate to biochemical and treatment variables. Seventy-three hemodialysis patients were questioned on the absence, occasional presence or daily recurrence (score = 0, 1, 2) of 14 symptoms and a record was made of their biochemical parameters, age, time on treatment and KtIV as a function of each symptom. The following relationships were detected: thirst with high Osm and BUN; asthenia with old age and hypoalbuminemia; insomnia with hypercalcemia; hypersomnia with hypoxemia and hypernatremia; anorexia with hypokalemia; dyspnea with old age, hypernatremia and hypokalemia; dysgeusia with hypoxemia; nausea with alkalemia, hypoxemia and low BUN; vomiting with alkalemia. Pruritus, arthralgia, restless legs syndrome, cramp and tremor showed no relationships. Monitoring acid-base balance and plasma electrolytes could help to alleviate symptoms and ameliorate quality of life of hemodialysis patients.

Clinical validation of PD Adequest software: modeling error assessment

OBJECTIVE

PD ADEQUEST software (Baxter Healthcare, Deerfield, IL, U.S.A.) is used in peritoneal dialysis for calculating the indices of dialysis efficiency and for the mathematical simulation of the results of various dialysis regimens. The aim of our study was to quantify the modeling errors and find the methods which give best results.

DESIGN

Nonrandomized, repeated measurement, clinical validation study.

PATIENTS

The study included 78 patients on continuous ambulatory peritoneal dialysis (PD), daytime ambulatory PD, and automated PD.

MEASUREMENTS

We used 207 collections of dialysate and urine associated with peritoneal equilibration tests (PETs) performed with different glucose concentrations (1.36%, 2.27%, 3.86%). The measured urea Kt/V, creatinine clearance (CRCL) and ultrafiltration (UF) were compared with the same data simulated mathematically using the PD ADEQUEST software version 1.4.

RESULTS

The Kt/V, CRCL, and UF measured values were significantly correlated and in agreement with modeled data [concordance correlation (rc) was 0.849, 0.839, 0.625 respectively]. The errors (modeled - measured) were: Kt/V = -0.04 +/- 0.27 (p = ns), CRCL = 2.1 +/- 7.7 L (p < 0.001), UF = -121 +/- 711 mL (p = 0.016). Applying ANOVA to both the peritoneal transport data calculated by PD ADEQUEST (mass transfer area coefficient of the solutes, fluid reabsorption, and hydraulic permeability) and the modeling errors, significant differences were found in relation to the PET glucose concentrations.

CONCLUSION

PD ADEQUEST proves to be a useful instrument in peritoneal dialysis, although there is undoubtedly still room for improvement in its prediction efficacy, which is influenced by the glucose concentration used in the PET.

Clinical evaluation of a new water removal measuring device in standard dialysis

A new device measuring water removal during standard dialysis is evaluated. The filtrate, collected from a small hemofilter inserted into a normal Cuprophan hollow-fiber dialyzer, was used to evaluate the total water removed from the patient. The device was tested in 46 patients undergoing regular dialysis treatment; the body weight loss ranged from 300 to 5,600 ml for a total of 71 dialysis sessions. Results confirmed the reliability of the device, as the mean prediction error was 5.4%. No influence of the dialyzer blood rest volume on the prediction error was observed. The authors propose this system as an alternative to bed or armchair scales and emphasize its usefulness for experimental purposes.

A new hemodialysis monitoring device using filtrate concentrations: a comparison with standard serum techniques

A new device allowing sampling to be performed at any time, and using the filtrate obtained during hemodialysis is described. The device was used in 27 patients undergoing regular dialysis. Urea, creatinine and potassium were measured in samples taken both from arterial blood and from the device at 10, 40, 120 and 230 minutes after the beginning of the dialysis. The results were compared. A constant bias of about 10% was noted between the two sets of results but statistical analysis showed this was correctable.

A pilot study of the pharmacokinetics and triglyceride lowering activity of acipimox in dialyzed uremic patients

The pharmacokinetics of acipimox was studied in 6 dialyzed uremic patients given single oral doses of 50 mg. Acipimox was not significantly eliminated outside dialysis, whereas during dialysis it was efficiently cleared with plasma, t 1/2 is about 2.6 hours. Accordingly, a dosage schedule of 50 mg or 100 mg of acipimox after each dialysis session was selected for a second, 4-week study in 14 uremic patients with hypertriglyceridemia. Acipimox plasma levels, monitored during the study, proved in agreement with those expected on a theoretical pharmacokinetic basis. A clear-cut reduction of serum triglyceride levels was also achieved.