Narrative review of theoretical considerations regarding HITHOC between past and future

Hyppocrates constructed the medicines-surgery-energy triangle which includes all therapeutical modalities. Hyperthermic intraoperative chemotherapy (HITHOC) is a synergy-based single stage multimodality treatment encompassing the locoregional manifestation of the systemic malignant process. Pleural space, thermal effect, lavage/irrigation and chemotherapy represent the basic science ports of the network hub: HITHOC. The malignant transformation and process of the pleural surface (and underlying lung) challenges space management and tissue control. Thermotherapy without local chemotherapy is insufficient, similar to the normothermic local irrigation aligned with anticancer agents. The local administration of combined heat-transfer fluid and chemotherapy with or without subsequent surgical removal offers reasonable outcome in extensive primary pleural neoplasms (malignant mesothelioma), advanced (> Stage IIIA) NSCLC, functionally inoperable lung cancer and pleural carcinosis from extrathoracic malignancies. Measured by symptom-free survival and the quality of life, HITHOC in its present form, offers a modest yet fully substantiated solution. HITHOC in combination with the local application of targeted therapy and/or immunotherapy administered in the pleural space are currently under investigation. Additional development including new acting substances, their solvents and the means regarding surgical delivery and anesthesiology techniques are sign posts up ahead. Level 2 evidence are required in order to stepping up the recommendation levels, rewriting protocols and guidelines, in which HITHOC earns its revered position in the decision making process it deserves.

Early cardiac dysfunction is rescued by upregulation of SERCA2a pump activity in a rat model of metabolic syndrome

AIM

Various components of metabolic syndrome associate with cardiac intracellular calcium (Cai 2+) mishandling, a precipitating factor in the development of heart failure. We aimed to provide a thorough description of early stage Cai 2+-cycling alterations in the fructose-fed rat, an experimental model of the disorder, where insulin resistance, hypertension and dyslipidaemia act cooperatively on the heart.

METHOD

Rats were fed with fructose-rich chow. After 6 weeks, echocardiography was performed, which was followed by measurements of myocardial Cai 2+ transients recorded by Indo-1 surface fluorometry in isolated perfused hearts. Sarcoplasmic reticulum (SR) Ca(2+) -ATPase (SERCA2a) activity was assessed by administration of its inhibitor cyclopiazonic acid (CPA). Mathematical model analysis of Cai 2+ transients was used to estimate kinetic properties of SR Ca(2+) transporters. Protein levels of key Ca(2+) handling proteins were also measured.

RESULTS

Echocardiography showed signs of cardiac hypertrophy, but in vivo and ex vivo haemodynamic performance of fructose-fed rat hearts were unaltered. However, a decline in Ca(2+) sequestration capacity (-dCai 2+/dt and decay time of Cai 2+ transients) was observed. Model estimation showed decreased affinity for Ca(2+) (higher K(m) ) and elevated V(max) for SERCA2a. Diseased hearts were more vulnerable to CPA application. Fructose feeding caused elevation in SERCA2a and phosphorylated phospholamban (PLB) expression, while total PLB level remained unchanged.

CONCLUSION

In early stage, metabolic syndrome primarily disturbs SERCA2a function in the heart, but consequential haemodynamic dysfunction is prevented by upregulation of SERCA2a protein level and phosphorylation pathways regulating PLB. However, this compensated state is very vulnerable to a further decline in SERCA2a function.