Prognostic and predictive significance of GITR in metastatic renal cell carcinoma

OBJECTIVE

Renal cell carcinoma (RCC) has gradually increased in recent years. There have been significant developments in metastatic RCC in recent years with the introduction of immune control point inhibitors. Glucocorticoid-induced tumor necrosis factor (TNF) receptor-related protein (GITR) is a co-stimulatory molecule and is seen in the highest amounts in activated CD4+ T lymphocytes and CD8+ T lymphocytes, forkhead box protein 3 (FOXP3) positive regulatory T cells (Treg). GITR leads to an increase in interleukin (IL)-2 and CD25 and Interferon Gamma. It shows an anti-tumoural effect by inhibiting the suppressive functions of FOXP3+ regulatory cells (Treg). Therefore, we aimed to evaluate the prognostic and predictive effect of GITR, tumor-infiltrating lymphocytes (CD4+CD8) (TIL), and FOXP3 in patients with metastatic RCC.

PATIENTS AND METHODS

Patients diagnosed with pathologically confirmed metastatic renal cancer between 2016 and 2021 were included in our study. Clinicopathological features and some laboratory tests were recorded. GITR, CD4, CD8, and FOXP3 were evaluated by immunohistochemistry (IHC) from biopsies or nephrectomy material and recorded.

RESULTS

The study included 41 patients. The median progression-free survival (PFS) was 10.5 months, and the median overall survival (OS) was 13.9 months. Median PFS was 7.9 months for the GITR-low group and 18.9 months for the GITR-high group. Median PFS was statistically significant and longer for the GITR-high group than the GITR-low group (p=0.003). When patients who received nivolumab in the 2nd line were evaluated, median PFS was found to be 5.7 months in the GITR-low group and 15.7 months in the GITR-high group. Median PFS was statistically significantly higher in the GITR-high group than in the GITR-low group (p=0.026).

CONCLUSIONS

In patients with metastatic RCC, higher GITR was associated with better PFS. At the same time, in patients using nivolumab, better PFS was seen in the GITR high group. If supported by prospective studies, GITR can be used as both a prognostic and predictive marker.

Atrial natriuretic peptide: could it be a marker for postoperative recurrent effusions after Fontan circulation in complex congenital heart defects?

Fontan operation and its modifications are used for the physiological correction of complex congenital heart malformations with functionally single ventricle. Atrial natriuretic peptide (ANP), a physiological diuretic and vasodilator that--together with the effects of cardiopulmonary bypass--plays an important role in the augmentation of capillary permeability in Fontan patients. The rise in right atrial pressure and wall stress is an important stimulus for the release of ANP. ANP levels were measured before and early after surgery in Fontan group (n = 20) and control group (n = 20, patients with simple cardiac defects) to study its influence on and association with mean right atrial pressure, pulmonary vascular resistance (PVR), systemic vascular resistance, amount of drainage during early and late postoperative period, duration of intensive care unit and hospital stay, and need for colloid supplement. Early postoperative ANP values showed a negative correlation with PVR (r = -0.55) and total drainage (r = -0.88). There was no significant change in ANP during surgery or in the postoperative period in control patients. Reduction of PVR and maintenance of efficient urine output are important in the management of Fontan circulation. We conclude that high levels of ANP measured early after Fontan operation can be used as a marker for the successful establishment of Fontan circulation in patients with complex congenital heart defects.

A rare case of mixed type total anomalous pulmonary venous connection and its surgical treatment

In the mixed types of total anomalous pulmonary venous connection, pulmonary veins frequently show an opening at the supracardiac and cardiac level. Rarely, some other combinations of mixed type cases have been reported in the literature. In the present case the right and left pulmonary veins formed two distinct venous chambers and showed supracardiac and infracardiac openings. Anastomosis of each of these common venous chambers was performed to the left atrium, separate from each other, by extracardiac approach. The patient had no hemodynamic problems in the postoperative period and showed no pulmonary venous obstruction in a control angiography performed after 9 months. He has not needed medication and has shown no limitation of activity during a follow-up of 5 years.

Anomalous origin of the left coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery (ALCA-PA) is a rare form of congenital heart disease. In this report, three cases with this anomaly are described; two patients presented in infancy with heart failure from myocardial ischemia and infarction, while the third was asymptomatic and ALCA-PA was diagnosed during evaluation of a residual murmur after surgery for associated cardiac defects (ventricular septal defect and patent arterial duct). All three cases underwent aorto-pulmonary tunnel repair (Tukeuchi procedure), and to our knowledge two of them are the first infantile cases reported in Turkey.

Early and moderate long-term results of a new surgical technique for repair of aortic coarctation

OBJECTIVE

From June 1987 to September 1995, 53 patients underwent a new technique of coarctation repair. This technique consists of complete mobilization of the left subclavian artery so that it can be pulled down as far as possible.

METHOD

After all the necessary clamping, the anterior wall of the aorta is incised longitudinally beginning on the anterior wall of the left subclavian artery and extending distally to the descending aorta 1-2 cm past the coarctation. The left subclavian artery is pulled down so that the proximal end of the incision can reach the distal end. Then, this longitudinal incision is sutured transversely with 5/0 or 6/0 polydioxanone and continuous technique, enlarging the coarctation site and also preserving the blood flow to the left upper limb. The ages of the patients ranged from 16 days to 20 years (mean 3.7 years). Thirty patients were younger than 1 year old. One patient (1.9%) died postoperatively due to persistent pulmonary hypertension.

RESULTS

There was no pressure gradient perioperatively through the coarctation site after the repair. The mean follow-up was 34.4 +/- 27.5 months (range 1-99 months). All patients but one were in class I effort capacity (NYHA). Doppler echocardiographic studies were performed in 45 patients postoperatively. There was no restenosis or aneurysm formation at the coarctation site and the mean pressure gradients were between 19.8 +/- 16.2 mmHg.

CONCLUSION

The authors experience indicates that this technique could be a good alternative to the subclavian flap aortoplasty because of the preservation of blood flow to the left arm.

Combined internal mammary artery graft for coronary artery revascularization

Five patients with multiple-vessel coronary artery disease underwent isolated coronary artery bypass grafting with a technique involving both internal mammary arteries and a small piece of interposed saphenous vein. The combined internal mammary artery grafts were used for sequential grafting. A total of 20 anastomoses were performed (average number, 4 anastomoses per patient). There were no operative deaths. Postoperative complications included reoperation for bleeding in 1 patient and diaphragmatic dysfunction in another. Postoperative coronary angiography 2 days before discharge (mean time, 10 days postoperatively) revealed that all the sequential anastomoses with the combined IMA graft were patent. Exercise tolerance tests performed 3 and 11 months postoperatively indicated excellent results and no ischemia. Based on this experience, we conclude that this method appears promising for multivessel coronary artery bypass grafting.

Retrograde coronary sinus perfusion of cold cardioplegic solutions in the presence of coronary arterial occlusions. Experimental study

Coronary arterial stenoses impose a constraint on the delivery of cold cardioplegic solutions conventionally perfused via the aortic root, resulting in uneven myocardial cooling and protection. Therefore the hearts undergoing coronary bypass operations show impaired cooling of the post-occlusive myocardial regions, and temperature gradients among different myocardial fields are registered after cold cardioplegic perfusion. We applied retrograde coronary sinus perfusion of cold cardioplegic solution in canine hearts with occluded multiple left coronary arterial branches to overcome the above-mentioned drawbacks, and a uniform left ventricular cooling was demonstrated by this technique.

Aortico-left ventricular tunnel

A 10-year-old boy with aortico-left ventricular tunnel, a very unusual congenital cardiovascular malformation, is presented. Closure of both orifices of the tunnel by round teflon patches is recommended. We think this surgical technique is superior to closure of these openings by primary sutures only, which can result in stretching and distortion of the aortic ring and leaflets leading to postoperative residual aortic regurgitation.

Intrapericardial aneurysm of the left atrial appendix

Aneurysms of the left atrium or its appendage are uncommon. Some occur with an intact pericardium and others are associated with a pericardial defect. The majority of patients are asymptomatic, but dysrhythmias and systemic embolism may occur. The condition should be suspected after chest radiography but can only be confirmed by angiocardiography. Resection is advised with cardiopulmonary bypass standing by. A patient with an intrapericardial aneurysm of the appendage correctly diagnosed by angiocardiography and successfully treated by simple excision is described.

Congenital double-orifice mitral valve. Report of a case with valve replacement

A case of double-orifice mitral valve (duplication of the mitral valve) in an 18-month-old baby is presented. The valve showed significant regurgitation and was replaced with a No. 20 Lillehei-Kaster mitral prosthesis. Patient is kept on dipyridamole (Persantin) 10 mg/Kg and aspirin 50 mg/Kg daily to avoid postoperative thromboembolic complications. It is emphasized that valve replacement should be the treatment of choice in severe mitral regurgitation associated with double-orifice mitral valve.

Congenital right coronary artery-right atrial fistula

A rare type of congenital fistula between the right coronary artery and the right atrium, where fistula was draining just above the inferior vena caval orifice, is presented. Patient was operated on utilizing cardiopulmonary bypass and the fistulous opening into the right atrium was closed by interrupted ti-cron sutures supported with teflon pledgets. The benefits of using cardiopulmonary bypass in these operations or at least having it stand-by in the operating room are emphasized for safer closure of the fistula when needed.

Congenital right coronary artery-right atrial fistula

A rare type of congenital fistula between the right coronary artery and the right atrium, where fistula was draining just above the inferior vena caval orifice, is presented. Patient was operated on utilizing cardiopulmonary bypass and the fistulous opening into the right atrium was closed by interrupted ti-cron sutures supported with teflon pledgets. The benefits of using cardiopulmonary bypass in these operations or at least having it stand-by in the operating room are emphasized for safer closure of the fistula when needed.

Open mitral commissurotomies. Analysis of 100 cases

Routine use of open mitral commissurotomy in all cases of rheumatic mistral stenosis is the recommended treatment of choice in recent years. Effective division of the subvalvular apparatus (chordae tendineae and papillary muscles) can be accomplished easily during open commissurotomy and therefore recurrences after the open approach is less than the recurrences after closed commissurotomy. These subvalvular elements can not be freed easily during closed mitral commissurotomy. Low mortality rates after open approach suggests that this operation can be performed safely in cases of MS. Open approach has several advantages versus closed commissurotomy. We believe that closed commissurotomy should be replaced by open commissurotomy in all cases of MS.

Cor triatriatum associated with large atrial septal defect and partial anomalous pulmonary venous return. Case report

A rare variant of cor triatriatum is presented with a large true atrial septal defect and partial anomalous pulmonary venous return into the right atrium. The correct diagnosis was made at the operation and abnormal left atrial septum was excised completely and a new interatrial septum was created with pericardial patch in such a position that the abnormally drained right upper pulmonary vein was left in the left atrium. It was thought to use the abnormal left atrial septum to close the atrial septal defect by excising only the right lateral border of this abnormal septum and resuturing it to the right atrial wall to close the true atrial septal defect. This thought could not be realized because of the small size of this abnormal septum and large size of the atrial septal defect. This technique can be realized in small or medium sized atrial septal defects associated with cor triatriatum.

Inhalation of foreign bodies in children. Report of 500 cases

Inhalation of foreign bodies is a major cause of accidental death during childhood. Aspiration of foreign bodies is common in children aged 1 to 3 years, especially in boys. A past history of foreign body aspiration is itself an indication for bronchoscopic examination of the airways, because some children with aspirated foreign bodies are without symptoms and chest x-ray films may not show abnormalities. Bronchoscopic removal of the foreign bodies requires close communication between the anesthesiologist and the endoscopist. Forgotten foreign bodies in the airways cause chronic pulmonary infections, allergic asthma, bronchiectatic changes, and lung abscess. Foreign bodies that cannot be grasped by bronchoscopic forceps should be removed by thoracotomy and bronchotomy. This report describes our experience in 500 children with suspected foreign body inhalation. We routinely use prednisolone, 1 to 2 mg. per kilogram, and nebulization just after bronchoscopic examination of the airways. This medication greatly diminishes the rate of postbronchoscopic complications such as laryngeal edema, which require tracheostomy. In our series of 500 case, the incidence of postbronchoscopic tracheostomy is 1.4 per cent and the total mortality rate is 1.8 per cent.

Pulmonary artery sling

A case of pulmonary artery sling in a 1-year-old boy, treated by resection of the left pulmonary artery (LPA) at its origin from the right pulmonary artery (RPA) and reanastomosis of the LPA to the main pulmonary artery (MPA), is reported. In this patient the LPA-MPA anastomosis was demonstrated to be patent in a follow-up pulmonary angiogram six months after the operation. Pulmonary artery sling should be kept in mine when assessing respiratory distesss syndrome in children.