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.

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.

Pulmonary hydatid disease: report of 100 patients.

One hundred patients with pulmonary hydatid disease underwent thoractomy and operative removal of the cysts. Of the 60 men and 40 women, most were between 3 and 19 years old. Cough, fever, dyspnea, and chest pain were the prominent symptoms in the majority of cases. Intact hydatid cysts were found in 67 patients and infected or ruptured cysts in 33. The Casoni skin test, Weinberg reaction, and eosinophilia were found to be unreliable diagnostic criteria and therefore were not used routinely in our patients. Roentgenological examination was the most valuable diagnostic aid. A single lobe was affected in 72 patients. Unilateral multiple foci were present in 15 patients and bilateral multiple foci in 13. Cystectomy and capitonnage were the preferred operative procedures in most cases. Pulmonary resection was necessary to only a limited number of patients. We conclude that conservative surgical methods such as cystectomy (with or without capitonnage) are preferable, especially for children, whose residual lung parenchyma has great capacity for expansion. The mortality rate among our 100 patients was 2%; both died of cardiac arrest during operation.

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.

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.

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.

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.

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.