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.

A case of hydatid cyst with intramural cardiac localization.

A 12-year-old boy with an intramural hydatid cyst of the heart is presented. In hydatid disease the incidence of cardiac cyst localization is less than 2%. The cyst was successfully excised by open heart surgery.

Use of transcutaneous electrical nerve stimulation in the control of postoperative chest pain after cardiac surgery.

The effect of continuous transcutaneous electrical nerve stimulation (TENS) on postoperative pain following median sternotomy was evaluated in 89 patients with severe chest pain who underwent cardiac surgery in a prospective, randomized, blinded trial. Pain was assessed by visual analog pain scores before and during treatment in each group. In the active TENS group, 79% of the patients were completely free of chest pain during rest at the end of 180 minutes (P less than 0.001). Among the remaining patients with TENS, 16% had slight pain not needing narcotic analgesics and 5% still had chest pain requiring narcotics. In the control group in which inactive TENS was used, the intensity of pain was reduced in 44% of the patients at the end of 90 minutes (P less than 0.001). However, this early placebo effect was noted to diminish with time and at the end of 180 minutes, 80% of the patients complained of severe chest pain and needed narcotics. These data suggest that TENS can be effective in controlling postoperative chest pain due to median sternotomy after cardiac surgery and its continuous application in the early postoperative period can reduce the need for narcotics.

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.