An epidemiological and clinicopathological study of type 1 vs. type 2 morphological subtypes of papillary renal cell carcinoma- results from a nation-wide study covering 50 years in Iceland.

INTRODUCTION: Papillary renal cell carcinoma (pRCC) is the second most common histology of renal cell carcinoma (RCC), accounting for 10-15% of cases. Traditionally, pRCC is divided into type 1 and type 2, although this division is currently debated as a prognostic factor of survival. Our aim was to investigate the epidemiology and survival of the pRCC subtypes in a whole nation cohort of patients during a 50-year period. MATERIALS AND METHODS: A Population based retrospective study including consecutive cases of RCC in Iceland from 1971-2020. Comparisons were made between histological classifications of RCC, with emphasis on pRCC subtypes (type 1 vs. 2) for outcome estimation. Changes in RCC incidence were analyzed in 5-year intervals after age standardization. The Kaplan-Meier method and Cox regression were used for outcome analysis. RESULTS: A total of 1.725 cases were identified, with 74.4%, 2.1% and 9.2% having clear cell (ccRCC), chromophobe (chRCC), and pRCC, respectively. The age standardized incidence (ASI) of pRCC was 1.97/100.000 for males and 0.5/100.000 for females, and the proportion of pRCC increased from 3.7% to 11.5% between the first and last intervals of the study (p < 0.001). Age standardized cancer specific mortality (ASCSM) of pRCC was 0.6/100.000 and 0.19/100.000 for males and females, respectively. The annual average increase in ASI was 3.6% for type 1 pRCC, but the ASI for type 2 pRCC and ASCSM for both subtypes did not change significantly. Male to female ratio was 4.4 for type 1 pRCC and 2.3 for type 2. The average tumor size for type 1 and 2 was 58.8 and 73.7 mm, respectively. Metastasis at diagnosis was found in 8.7% in the type 1 pRCC, compared to 30.0% of patients with type 2 pRCC (p < 0.001). Estimated 5-year cancer-specific survival (CSS) were 94.4%, 80.7%, and 69.3% for chRCC, pRCC and ccRCC, respectively (p < 0.001). For the pRCC subtypes, type 1 was associated with better 5-year CSS than type 2 (86.3% vs. 66.0%, p < 0.001), although this difference was not significant after adjusting for cancer stage and grading. CONCLUSIONS: pRCC histology was slightly less common in Iceland than in other countries. Males are more than three times more likely to be diagnosed with pRCC, compared to other RCC histologies. The subtype of pRCC was not found to be an independent risk factor for worse survival, and as suggested by the most recent WHO Classification of Urinary Tumors, grade and TNM-stage seem to be the most important factors for estimation of survival for pRCC patients.

A successful shift from thoracotomy to video-assisted thoracoscopic lobectomy for non-small cell lung cancer in a low-volume center.

OBJECTIVES: Although video-assisted thoracoscopic surgery (VATS) lobectomy has become the gold standard for pulmonary resections of non-small-cell lung cancer (NSCLC), lobectomy is still performed via thoracotomy in many European and North American centres. VATS lobectomy was implemented overnight from thoracotomy in our low-volume centre in early 2019, after 1 senior surgeon undertook observership VATS-training overseas, and immediately became the mainstay of surgical treatment for NSCLC in Iceland. We aimed to investigate our short-term outcomes of VATS lobectomy. METHODS: This was a retrospective study on all pulmonary resections for NSCLC in Iceland 2019-2022, especially focusing on VATS lobectomies, all at cTNM stage I or II. Data were retrieved from hospital charts, including information on perioperative complications, mortality, length of stay and operation time. RESULTS: Out of 204 pulmonary resections, mostly performed by a single senior cardiothoracic surgeon, 169 were lobectomies (82.9%) with 147 out of 169 (87.0%) being VATS lobectomies. Anterolateral thoracotomy was used in 34 cases (16.7%), including 22 lobectomies (64.7%), and 5 (3.4%) conversions from VATS lobectomy. The median postoperative stay for VATS lobectomy was 4 days and the average operating time decreased from 155 to 124 min between the first and last year of the study (P < 0.001). The rate of major and minor complications was 2.7% and 15.6% respectively. One year survival was 95.6% and all patients survived 30 days postoperatively. CONCLUSIONS: The implementation of VATS lobectomy has been successful in our small geographically isolated centre, serving a population of 390 000. Although technically challenging, VATS lobectomy was implemented fast for most NSCLC cases, with short-term outcomes that are comparable to larger high-volume centres.

[Incidence and outcomes of perioperative myocardial infarction associated with coronary artery bypass surgery].

INTRODUCTION: Perioperative myocardial infarction (PMI) after CABG can contribute to in-hospital morbidity and mortality, however, its clinical significance on long-term outcome, remains inadequately addressed. We studied both 30-day mortality and long-term effects of PMI in Icelandic CABG-patients. MATERIALS AND METHODS: A retrospective nationwide-study on 1446 consecutive CABG-patients operated at Landspitali in Iceland 2002-2018 without evidence of preoperative myocardial infarction. PMI was defined as a tenfold elevetion in serum-CK-MB associated with new ECG changes or diagnostic imaging consistent with ischemia. Patients with PMI were compared to a reference group with uni- and multivariate analyses. Long-term and MACCE-free survival were estimated with the Kaplan-Meier method and logistic regression used to determine factors associated with PMI. The mean follow-up time was 8.3 years. RESULTS: Out of 1446 patients 78 (5.4%) were diagnosed with PMI (range: 0-15.5%) with a significant annual decline in the incidence of PMI (12.7%, p<0.001). Over the same period preoperative aspirin use increased by 22.3% (p<0.018). PMI patients had a higher rate of short-term complications and a 11.5% 30-day mortality rate compared to 0.4% for non-PMI patients. PMI was found to be a predictor of 30-day mortality (OR 15.44, 95% CI: 6.89-34.67). PMI patients had worse 5-year MACCE-free survival (69.2% vs. 84.7, p=0,01), although overall survival was comparable between the groups. CONCLUSIONS: Although PMI after CABG is associated with significantly higher rates of short-term complications and 30-day mortality, long-term survival was similar to the reference group. Therefore, the mortality risk attributable to PMI appears to diminish after the immediate postoperative period.

[New-onset postoperative atrial fibrillation following coronary artery bypass grafting: Incidence, clinical course and short-term outcomes].

INTRODUCTION: The aims of this retrospective study were to investigate the incidence, clinical course and short term outcomes of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass surgery (CABG). MATERIALS AND METHODS: A nation-wide study on 1622 patients who underwent CABG from 2006-2020 at Landspitali University Hospital. Clinical data were extracted from registries and 121 patients with pre-existing AF excluded, leaving 1501 patients for further analysis. Patient charts and postoperative ECGs were manually reviewed for determining details of POAF, which was defined as a postoperative episode of AF before discharge lasting at least 5 minutes. Patients with POAF (n=483) were compared to non-POAF patients (n=1018). RESULTS: Altogether 483 (32.2%) patients developed POAF; the annual incidence decreasing over time (tau= -0,45, p=0.023). Most patients were diagnosed on the second day postoperatively (43.5%) and over 90% were diagnosed within 4 days. The median number of POAF episodes was 3 (IQR: 1-5), the first episode lasting 1-6 hours in half of the cases and the total POAF-duration being 12 hours median (IQR: 5-30). Over 94% of cases converted to sinus rythm before discharge, with 25 (5.3%) patients being discharged in AF. Most patients were treated with beta-blockers (98.8%), amiodarone (95%) and 14.9% with electric cardioversion. POAF-patients were older, had higher EuroSCORE II and a longer hospital stay, however, they had similar rates of early postoperative stroke and 30 day mortality. CONCLUSION: The incidence of POAF remains high and was associated with prolonged hospital stay, but not significantly higher 30 day mortality or early postoperative stroke compared to patients in sinus rhythm. POAF-episodes were predominantly transient and almost 95% of patients were discharged in sinus rythm.

[The effect of obesity on the outcome of surgical aortic valve replacement for aortic stenosis].

INTRODUCTION: Our objective was to investigate the effect of obesity on short-term complications and long-term survival after surgical aortic valve replacement (SAVR) for aortic stenosis (AS). MATERIAL AND METHODS: A retrospective study on 748 patients who underwent SAVR for AS in Iceland 2003-2020. Patients were divided into groups based on body mass index (BMI): normal (18.5-24.9 kg/m2, n=190), overweight (25-29.9 kg/m2, n=339), obese (30-34.9 kg/m2, n=165) and severely obese (≥35 kg/m2, n=54). Six patients with BMI p<18,5 kg/m2 were excluded. Clinical information regarding patient history, risk factors, together with complications and 30-day mortality were collected from patient records. The four BMI groups were compared and long-term survival estimated with Kaplan-Meier plots and risk factors for long-term survival evaluated with Cox multivariate analysis. RESULTS: Severely obese patients were on average four years younger than patients with normal BMI, more often had risk factors for cardiovascular disease, and their EuroSCORE II was higher (5.3 vs. 4.4%, p=0.03). On the other hand, severely obese patients bled less the first 24 hours post-surgery, compared to normal BMI-patients (558 vs. 1091 ml, p<0.001), stroke was less frequent (0 vs 6.4%, p=0.03), but they more often experienced sternum dehiscence (5.6 vs 2.7%, p=0.04), deep sternal wound infection (3.7 vs 0%, p=0.04) and acute kidney injury (26.4 vs 15.2%, p=0.005). Thirty-day mortality and long-term survival did not differ significantly between the groups and BMI was not an independent predictor of long-term survival in multivariate analysis. CONCLUSIONS: The outcome for obese patients undergoing SAVR for AS is good and both short-term complications and long-term survival do not differ significantly from patients with a normal BMI. Therefore, a high BMI itself should not be a contraindication for SAVR due to AS.

Non-infectious sternal dehiscence after coronary artery bypass surgery.

INTRODUCTION: Non-infectious sternal dehiscence (NISD) is a known complication following coronary artery bypass grafting (CABG), with previous studies estimating an incidence of 0.4-1% of surgeries. We aimed to study the incidence of NISD together with short- and long-term outcomes in a whole-nation cohort of patients. MATERIALS AND METHODS: A retrospective study on consecutive CABG patients diagnosed with NISD at Landspitali from 2001 to 2020. Patients diagnosed with infectious mediastinitis (n = 20) were excluded. NISD patients were compared to patients with an intact sternum regarding patient demographics, cardiovascular risk factors, intra- and postoperative data, and estimated overall survival. The median follow-up was 9.5 years. RESULTS: Twenty out of 2280 eligible patients (0.88%) developed NISD, and the incidence did not change over the study period (p = 0.98). The median time of diagnosis was 12 days postoperatively (range, 4-240). All patients were re-operated using a Robicsek-rewiring technique, with two cases requiring a titanium plate for fixation. Patients with NISD were older, had a higher BMI and EuroSCORE II, lower LVEF, and more often had a history of COPD, MI, and diabetes compared to those without NISD. Length of stay was extended by 15 days for NISD patients, but short and long-term survival was not statistically different between the groups. CONCLUSIONS: The incidence of NISD was low and in line with previous studies. Although the length of hospital stay was extended, both short- and long-term survival of NISD patients was not significantly different from patients with an intact sternum.

[Short- and long-term outcomes following surgery for primary spontaneous pneumothorax in Iceland].

BACKGROUND: Primary spontaneous pneumothorax (PSP) is a common disease where surgery is indicated for persistant air leak or recurrent pneumothorax. We studied the outcomes of PSP-surgery over a 28 year period in a whole nation. MATERIALS AND METHODS: A retrospective study on 386 patients (median age 24 years, 78% males) that underwent 430 PSP surgeries at Landspitali University Hospital 1991-2018. Annual incidence of the procedure was calculated and previous medical history, indication and type of surgery, complications and length of hospital stay were registered. Patients in four 7 year periods were compared, recurrent pneumothoraces requiring reoperation (median follow-up 16 years) registered and predictors of reoperation identified with logistic regression. RESULTS: Annually 14.5 PSP surgeries (median, range 9-27) were performed; the incidence decreasing by 2.9% per year on average. Every other patient smoked and 77% of surgeries were performed with video assisted thoracocopic surgery (VATS). The most common early complications (p<30 days from surgery) were persistent airleak (17%), pneumonia (2%) and empyema (0,5%). No patient died within 30 days from surgery. Reoperation for recurrent pneumothorax was performed on 27 patients; 24 following VATS (7%), median time from the primary surgery being 16 months. Logistic regression showed that younger patients were more likely to require reoperation for recurrent pneumothorax. CONCLUSIONS: Surgical treament for PSP is safe and major early complications rare. The rate of recurrent pneumothorax requiring surgery was 6%, which is similar to other studies. For unknown reasons the incidence of PSP surgery declined, but future research has to answer if it is linked to decreased smoking in the Icelandic population.

A retrospective study on adherence to secondary prevention medications after coronary bypass surgery.

OBJECTIVES: We assessed adherence to statins, beta-blockers and renin-angiotensin system (RAS) inhibitors after coronary artery bypass graft surgery and factors associated with non-adherence. METHODS: This nationwide retrospective cohort study included all individuals undergoing coronary artery bypass surgery from 22 May 2007 to 20 December 2018, at Landspitali-the National University Hospital (n = 1536). Data on dispensed prescriptions were retrieved from the National Prescription Medicine Registry. Adherence was estimated by the proportion of days covered up to 2 years after hospital discharge, with cut-offs for strict adherence and non-adherence at over 80% and under 50%, respectively. Multivariable logistic regression was used to assess variables associated with non-adherence. RESULTS: Criteria for strict adherence were met by 39.2%, 36.9% and 30.1% of patients for statins, beta-blockers and RAS inhibitors, respectively. Non-adherence criteria were met for 14.4%, 25.9% and 43.6% of patients for statins, beta-blockers and RAS inhibitors, respectively. High Hospital Frailty Risk Score Class (statins: odds ratio (OR) 2.29, confidence interval (CI) 1.02-4.86; RAS inhibitors: OR 2.06, CI 1.04-4.04), concomitant aortic valve replacement (statins: OR 1.64, CI 1.11-2.38; RAS inhibitors: OR 1.78, CI 1.26-2.52) and a new prescription for a medication class following surgery (statins: OR 2.87, CI 2.06-4.01; beta-blockers: OR 1.70, CI 1.32-2.18; RAS inhibitors: OR 6.95, CI 5.27-9.25) were associated with non-adherence. CONCLUSIONS: Non-adherence to medical therapy after coronary artery bypass surgery is common. Patients with a higher burden of frailty and patients naive to the medical treatment of coronary artery disease should be a target group for efforts to increase medication adherence.